Miami-Dade County's Affidavits and Declarations . (3 th—02t211e-S
Miami-Dade County's Affidavits and Declarations
MIAMI-DADE ¢'
COUNTY "'
Miami-Dade County requires each party desiring to enter into a contract with Miami-Dade County to;
(1) sign an affidavit as to certain matters and (2) make a declaration as to certain other matters. This
form contains both an Affidavit form for matters requiring the entity to sign under oath and a Declaration
form for matters requiring only an affirmation or declaration for other matters.
Each section of this form must be read, and initialed indicating acceptance and/or compliance with the
County's policy related to the particular affidavit. For affidavit sections that you do not believe are
applicable to your organization,please indicate this by placing"x" in the box next to N/A.
ALL SECTIONS MUST BE COMPLETED
THE FOLLOWING MATTERS REQUIRE THE ENTITY TO SIGN AN AFFIDAVIT UNDER OATH:
STATE OF ( F-L-OR I DA )
COUNTY.OF ( M a AM I - DA DE )
COUNTRY OF (U.SA )
Before me the undersigned authority appeared
(Print Name), Si N+M y L- M O R A Le 5 who is personally known to me or who has provided
as identification and who did swear to the following:
That he or she is the duly authorized representative of(Name of Entity) C I 1-NI OF MIAMI SEAC.1-1
(Address of Entity) I -00 CO ivvE NTI(Div GEhr r R (DR 1vI Post Office
addresses are not acce table.
59 - Go00 -34 2
Federal Employment Identification Number
G »'v or- M i AM I @EA al-I (hereinafter referred to as the contracting
"entity"), and that he or she is the entity's (Sole Proprietor)(Partner)(President or Other Authorized Officer)
C ITY MANAGE R
That he or she has full authority to make this affidavit, and that the information given herein and the documents
attached hereto are true and correct; and
That he or she says as follows:
ATTACHMENT f C 1 Miami-Dade County Affidavits and Declarations Page 1 of 10
Miami-Dade County's Affidavits and Declarations
1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT(SECTION 2-8.1 Pertains O
OF THE COUNTY CODE) N/A
If the contract or business transaction is with a corporation,the full legal name and business address shall be
provided for each officer and director and each stockholder who holds directly or indirectly five percent(5%) or
more of the corporation's stock. .
If the contract or business transaction is with a partnership,the foregoing information shall be provided for
each partner.
If the contract or business transaction is with a trust,the full legal name and address shall be provided for each
trustee and each beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded
corporations or to contracts with the United States or any department or agency thereof,the State or any
political subdivision or agency thereof or any municipality of this State. All such names and address are outlined
below:Post Office addresses are not acceptable.
(Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership)
(Full Legal Name,Address,%Ownership) (Full Legal Name,Address,%Ownership)
The full legal names and business address of any other individual (other than subcontractors,material person,
suppliers,laborers, or lenders)who have,or will have,any interest(legal,equitable beneficial or otherwise)in
the contract or business transaction with Miami Dade County are:
Post office addresses are not acceptable
Any person who willfully fails to disclose the information required herein, or who knowingly discloses false.
information in this regard,shall be punished by a fine of up to five hundred dollars ($500.00) or imprisonment
in jail for up to sixty(60) days or both.
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ATTACHMENT(C)Miami-Dade County Affidavits and Declarations Page 2 of 10
Miami-Dade County's Affidavits and Declarations
2. MIAMI-DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT(COUNTY Pertains
ORDINANCE 90-133,AMENDING SECTION 2.8-1;SUBSECTION (d)(2) OF THE N/A
COUNTY CODE)
Except where precluded by Federal or State laws or regulations,each contract or business transaction or
renewal thereof which involves the expenditure of then thousand dollars ($10,000) or more shall require the
entity contracting or transaction business to disclose the following information: The foregoing disclosure
requirements do not apply to contracts with the United States or any department or agency thereof,the State or
any political subdivision or agency thereof or any municipality of this State.
Does your firm have a collective bargaining agreement with its employees? s4 Yes O No
Does your firm provide paid health care benefits for its employees?V,1Yes O No
Provide a current breakdown(number of persons) of your firm's work force and ownership (below):
White: Males Z.q3 Females 1 op
Males LFemales i EZ
Black: ��5�
Hispanic: Males S i t Females 3 i µ
Asian: Males Females 5
American Native: Males 2 Females '&?
Aleut(Eskimo): Males c'S? Females
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Miami-Dade County's Affidavits and Declarations
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3. MIAMI-DARE COUNTY AFFIRMATIVE ACTION/
NONDISCRIMINATION OF EMPLOYMENT,PROMOTION AND Pertains XI
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PROCUREMENT PRACTICES(COUNTY ORDINANCE 98-30 CODIFIED N/A O
AT 2-8.1.5 OF THE COUNTY CODE)
Pursuant to Miami-Dade County's Ordinance No.98-30,Section 2-8.1.5,entities with annual gross revenue in
excess of$5,000,000 seeking to contract with the County shall,as a condition of receiving a County contract,have:
1)a written affirmative action plan which sets forth the procedures the entity utilizes to assure that it does not
discriminate in its employment and promotion practices and 2) a written procurement policy which sets forth the
procedures the entity utilizes to assure that it does not discriminate against minority and women-owned
businesses in its own procurement of goods,supplies and services.Such affirmative action plans and procurement
policies shall provide for periodic review to determine their effectiveness in assuring the entity does not
discriminate in its employment,promotion and procurement practices.The foregoing,not withstanding,corporate
entities whose board of directors are representative of the population make-up of the nation shall be presumed to
have non-discriminatory employment and procurement policies,and shall not be required to have a written
affirmative action plan and procurement policy in order to receive a County contract.The foregoing presumption
maybe rebutted.The requirements of this section may be waived upon written recommendation of the County
Manager that it is in the best interest of the County to do so and approval of the County Commission by majority
vote of the members present Based on the above,please complete the affidavit as directed and return the
completed affidavit along with a cover letter on your company's letterhead,listing the company's address,phone ,
and fax numbers,and any required documents,to:Miami-Dade County,Department of Procurement
Management Affirmative Action Plan Unit 111 NW 1st Street,13th Floor Miami,FL 33128
Yes l I) No O My company has an affirmative action plan and procurement policy and is
available for review.
My company has annual gross revenues in excess of$5,000,000.
Yes No O Therefore,our company's affirmative action plan and procurement policy
is available for review.
Yes O No (t) My company has annual gross revenues less than$5,000,000.
If at any time the Miami Dade County has reason to believe that any person or firm has willfully and knowingly
provided incorrect information or made false statements,the County may refer the matter to the State Attorney's
Office and/or other investigative agencies.The County may initiate debarment and/or pursue other remedies in
accordance with Miami-Dade County policy and/or applicable federal,state and local laws.
4. MIAMI-DADE COUNTY CRIMINAL RECORD AFFIDAVIT Pertains �l
(SECTION 2-8.6 OF THE COUNTY CODE) N/A D
The individual or entity entering into a contract or receiving funding from Miami-Dade County O has O has not,
as of the date of this affidavit,been convicted of a felony during the past ten (10)years.
An officer, director,or executive officer of the entity entering into a contract or receiving funding from Miami-Dade
County O has tg)has not as of the date of this affidavit been convicted of a felony during the past ten(10)years.
L
ATTACHMENT(C)Miami-Dade County Affidavits and Declarations Page 4 of 10
Miami-Dade County's Affidavits and Declarations
5. PUBLIC ENTITY CRIMES AFFIDAVIT(SECTION Pertains ki
287.133(3)(a),FLORIDA STATUTES) N/A O
contract or receiving funding individual or entity entering into a con g g from Miami-Dade County understands the
following: That a"public entity crime"as defined in Paragraph 287.133 (1) (g) Florida Statutes,means a violation
of any state or federal law by a person with respect to and directly related to the transaction of business with any
public entity or with an agency or political subdivision of any other state of the United States of America,including
but not limited to,any bid or contract for goods or services to be provided to any public entity or an agency or
political subdivision of any other state of the United States of America and involving antitrust,fraud,theft,bribery,
collusion,racketeering, conspiracy,or material misrepresentation.
That"Convicted" or"conviction"as defined in Paragraph 287.133 (1) (b) Florida Statutes means a finding of guilt
or a conviction of a public entity crime,with or without an adjudication of guilt,in any federal state trial court of
record relating to charges brought by indictment or information after July 1,1989,as a result of a jury verdict,non-
jury trial,or entry of plea of guilty or nolo contendere.
That an"affiliate" as defined in Paragraph 287.133 (1) (a) Florida Statutes means a) a predecessor or successor of a
person convicted of a public entity crime; or b) an entity under the control of any natural person who is active in
the management of the entity and who has been convicted of a public entity crime. The term"affiliate"includes
those officers, directors, executives,partners,shareholders, employees,members, and agents who are active in the
management of an affiliate. The ownership by one person of shares constituting a controlling interest in another
person,or pooling of equipment or income among persons when not for fair market value under an arm's length
agreement,shall be a prima facie case that one person controls another person. A person who knowingly enters
into a joint venture with a person who has been convicted of a public entity crime in Florida during the preceding
36 months shall be considered an affiliate.
That a"person" as defined in Paragraph 287.133 (1) (e) Florida Statutes means any natural person or entity
organized under the laws of any state or of the United States of America with the legal power to enter into a
binding contract and which bids or applies to bid on contracts for the provision of goods or services let by a public
entity, or which otherwise transacts or applies to transact business with a public entity. The term"person"
includes those officers, directors, executives,partners,shareholders, employees,members and agents who are
active in the management of an entity.
Based on information and belief,the statement as marked below,is true in relation to the entity submitting this
sworn statement. (Please indicate which statement applies by applying the individual initials near the box).
tigj Neither the entity submitting this sworn statement nor any of its officers,directors, executives,partners,
shareholders, employees,members or agents Who are active in the management of the entity,nor an affiliate of the
entity has been charged with and convicted of a public entity crime within the past 36 months.
O The entity submitting this sworn statement or one or more of its officers,directors, executives,partners,
shareholders, employees,members or agents who are active in the management of the entity,or an affiliate of the
entity has been charged with and convicted of a public entity crime within the past 36 months; and
O yes an additional statement is applicable or O no an additional statement is not applicable.
O The entity submitting this sworn statement, or one or more of its officers, directors,executives,partners,
shareholders, employees,members,or agents who are active in the management of the entity has been charged
with and convicted of a public entity crime within the past 36 months. However,there have been subsequent
proceedings before a Hearing Officer of the State of Florida, Division of Administrative Hearings and the Final
Order entered by the Hearing Officer determined that it was not in the public interest to place the.entity submitting
this sworn statement on the"Convicted Vendor List".
The individual or entity entering into a contract or receiving funding from Miami-Dade County understands that he
or she is required to inform the public entity prior to entering into a contract in excess of the threshold amount
provided in Section 287.017 Florida Statues for Category 2 of any change in the information contained in this form.
n,,TO c ndi n
Miami-Dade County's Affidavits and Declarations
6.MIAMI-DADE EMPLOYMENT FAMILY LEAVE AFFIDAVIT Pertains
(County Ordinance No.142-91 codified as Section 11A-29 et. N/A
seq of the County Code)
That in compliance with Ordinance No.142-91 of the Code of Miami-Dade County,Florida,an employer with fifty
(50) or More employees working in Dade County for each working day during each of twenty(20) or more
calendar work weeks,shall provide the following information in compliance with all items in the aforementioned
ordinance:
An employee who has worked for the above firm at least one (1)year shall be entitled to ninety(90) days of family
leave during any twenty-four (24)month period,for medical reasons,for the birth or adoption of a child,or for the
care of athild,spouse or other close relative who has a serious health condition without risk of termination of
employment or employer retaliation:
The foregoing requirements shall not pertain to contracts with the United States or any department or agency
thereof,or the State of Florida or any political subdivision or agency thereof. It shall,however,pertain to
municipalities of this State.
7. MIAMI-DADE COUNTY DISABILITY NONDISCRIMINATION Pertains
AFFIDAVIT (County Resolution R-385-95) N/A O
That the above named firm,corporation or organization is in compliance with and agrees to continue to comply
with,and assure that any subcontractor, or third party contractor under this project complies with all applicable
requirements of the laws listed below including,but not limited to those provisions pertaining to employment,
provision of programs and services,transportation,communications,access to facilities,renovations,and new
construction in the following laws:The Americans with Disabilities Act of 1990 (ADA),Pub.L.101-336, 104 Stat
327,42 U. S.C.12101-12213 and 47 U.S.C.Sections 225 and 611 including Title I, Employment;Title II,Public
Services;Title III, Public Accommodation and Services Operated by Private Entities;Title IV,Telecommunications;
and Title V, Miscellaneous.Provisions:The Rehabilitation Act of 1973, 29 U.S.C.Section 794:The Federal Transit
Act,as amended 49 U .S.' C.Section 1612:The Fair Housing Act as amended,4 2 U.S.C.Section 3601-3631.The
foregoing requirements shall not pertain to contracts with the United States or any department or agency thereof,
or the State or any political subdivision or agency thereof or any municipality of this State.
8.MIAMI-DARE COUNTY REGARDING DELINQUENT AND CURRENTLY DUE Pertains I1
FEES OR TAXES(Sec.2-8.1(c) of the County Code) N/A O
Except for small purchase orders and sole source contracts,that above named firm,corporation,organization or
individual desiring to transact business or enter into a contract with the County verifies that all delinquent and
currently due fees or taxes--including but not limited to real and property taxes,utility taxes and occupational
licenses--which are collected in the normal course by the Dade County Tax Collector as well as Dade County
issued parking tickets for vehicles registered in the name of the firm, corporation, organization or individual have
been paid:
ATTACHMENT(C)Miami-Dade County Affidavits and Declarations Page 6 of 10
Miami-Dade County's Affidavits and Declarations
Pertains .)
9. CURRENT ON ALL COUNTY CONTRACTS,LOANS AND OTHER OBLIGATIONS N/A ❑
The individual entity seeking to transact business with the County is current in all its obligations to the County and
is not otherwise in default of any contract,promissory note or other loan document with the County or any of its
agencies or instrumentalities.
10. DOMESTIC VIOLENCE LEAVE (Resolution 185-00; 99-5 Codified At 11A- Pertains
60 Et.Seq.of the Miami-Dade County Code). N/A ❑
The firm desiring to do business with the County is in compliance with Domestic Leave Ordinance,Ordinance 99-
5, codified at 11A-60 et.seq.of the Miami Dade County Code,which requires an employer which has in the regular
course of business fifty(50) or more employees working in Miami-Dade County for each working day during each
of twenty(20) or more calendar work weeks in the current or proceeding calendar years,to provide Domestic
Violence Leave to its employees.
11. MIAMI-DADE COUNTY EMPLOYMENT DRUG-FREE WORKPLACE Pertains
AFFIDAVIT (County Ordinance No.92-15 codified as Section 2- N/A ❑
8.1.2 of the County Code)
That in compliance with Ordinance No.92-15 of the Code of Miami-Dade County, Florida,the above named person
or entity is providing a drug-free workplace.A written statement to each employee shall inform the employee
about:
1. danger of drug abuse in the workplace;
2. the firm's policy of maintaining a drug-free environment at all workplaces;
3. availability of drug counseling,rehabilitation and employee assistance programs;
4. penalties that may be imposed upon employees for drug abuse violations.
The person or entity shall also require an employee to sign a statement,as a condition of employment that the
employee will abide by the terms and notify the employer of any criminal drug conviction occurring no later than
five (5) days after receiving notice of such conviction and impose appropriate personnel action against the
employee up to and including termination.
Compliance with Ordinance No. 92-15 maybe waived if the special characteristics of the product or service offered
by the person or entity make it necessary for the operation of the County or for the health,safety,welfare economic
benefits and well-being of the public.Contracts involving funding which is provided in whole or in part by the
United States or the State of Florida shall be exempted from the provisions of this ordinance,in those instances
where those provisions are in conflict with the requirements of those governmental entities.
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Miami-Dade County's Affidavits. and Declarations • '
12. ATTESTATION REGARDING DUE AND PROPER ACKNOWLEDGEMENT OF Pertains �l
COUNTY FUNDING SUPPORT N/A 0
By initialing this subsection and accepting County funds,the above named firm, corporation, organization or
individual agrees to abide by the grant contract requirement to recognize and acknowledge Miami-Dade County's
grant support in a manner commensurate with all contributors and sponsors of its activities at comparable dollar
levels.
13.MIAMI-DADE COUNTY RESOLUTION NO.R-630-13 REQUIRING A DETAILED
PROJECT.BUDGET,SOURCES AND USES STATEMENT,CERTIFICATIONS AS pertains O
TO PAST DEFAULTS ON AGREEMENTS WITH NON-COUNTY FUNDING N/A
SOURCES,AND DUE DILIGENCE CHECK
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Pursuant to Miami-Dade County Resolution No.R-630-13,requiring a detailed project budget,sources and uses
statement,certifications as to past defaults on agreements with non-county funding sources and due diligence
check prior to the County Mayor or County Mayor's designee recommending a commitment of Miami-Dade County
funds to.Social Services,Economic Development, Community Development,and Affordable Housing Agencies and
Providers.
The undersigned entity certifies,to the best of his or her knowledge and belief,that:
1. Within the past five (5)years,neither the Agency nor its directors,partners,principals,members or board
members:
(i) have been sued by a funding source for breach of contract or failure to perform obligations under a
contract;
(ii) have been cited by a funding source for non-compliance or default under a contract;
(iii) have been a defendant in a lawsuit based upon a contract with a funding source.
Please list any matters which prohibit the Agency from making the certifications required and explain how the
matters are being resolved(use separate sheet if necessary):
14.MIAMI-DADE COUNTY RESOLUTION No.R-478-12 NOT TO USE PRODUCTS Pertains
OR FOODS CONTAINING"PINK SLIME" N/A 0
Pursuant to Miami-Dade County Resolution No.R-478-12,the undersigned certifies,not to use meat products
containing"Pink Slime"in food provided or served as part any food program;urging all who provide food services
or operate a food program to immediately discontinue using meat products containing"pink slime"in food
provided or served in these,programs. -
ATTACHMENT(C)Miami-Dade County Affidavits and Declarations - Page 8 of 10
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Miami-Dade County's Affidavits and Declarations
15.MIAMI-DADE COUNTY REQUIRED LOBBYIST REGISTRATION FOR ORAL Pertains O
PRESENTATION Section 2-11.1(i)(2) CONFLICT OF INTEREST AND CODE N/A �j
OF ETHICS ORDINANCE
All lobbyists shall register with the Clerk of the Board of County Commissioners within five (5)business days of
being retained as a lobbyist or before engaging in any lobbying activities,whichever shall come first. Every person
required to so register shall:
1.Register on forms prepared by the Clerk;
2.State under oath his or her name,business address and the name and business address of each person or entity
which has employed said registrant to lobby.If the lobbyist represents a corporation,the corporation shall also be
identified.Without limiting the foregoing,the lobbyist shall also identify all persons holding, directly or indirectly,
a five (5) percent or more ownership interest in such corporation,partnership, or trust.Registration of all
lobbyists shall be required prior to January 15 of each year and each person who withdraws as a lobbyist for a
particular client shall file an appropriate notice of withdrawal.
3.Prior to conducting any lobbying,all principals must file a form with the Clerk of the Board of County
Commissioners,signed by the principal or the principal's representative,stating that the lobbyist is authorized to
represent the principal. Failure of a principal to file the form required by the preceding sentence maybe
considered in the evaluation of a bid or proposal as evidence that a proposer or bidder is not a responsible
contractor.Each principal shall file a form with the Clerk of the Board at the point in time at which a lobbyist is no
longer authorized to represent the principal.
1 By initialing here,the principals or principal's representative have filed with the Clerk of the Board of
County Commissioners stating that a lobbyist is authorized to represent the principal.
4.Any public officer, employee or appointee who only appears in his or her official capacity shall not be required to
register as a lobbyist.
5.Any person who only appears in his or her individual capacity for the purpose of self-representation without
compensation or reimbursement,whether direct,indirect or contingent,to express support of or opposition to any
item,shall not be required to register as a lobbyist.
6.Any person who only appears as a representative of a not-for-profit corporation or entity(such as a charitable
organization, or a trade association or trade union),without special compensation or reimbursement for the
appearance,whether direct,indirect or contingent,to express support of or opposition to any item, shall register
with the Clerk as required by the Ordinance subsection,but,upon request,shall not be required to pay any
registration fees.
The Clerk of the Board of County Commissioners shall notify the Commission on Ethics and Public Trust of the
failure of a lobbyist or principal to file a report and/or pay the assessed fines after notification. A lobbyist or
principal may appeal a fine and may request a hearing before the Commission on Ethics and Public Trust.A request
for a hearing on the fine must be filed with the Commission on Ethics and Public Trust within fifteen(15) calendar
days of receipt of the notification of the failure to file the required disclosure form.The Commission on Ethics and
Public Trust shall have the authority to waive the fine,in whole or part,based on good cause shown.The
Commission on Ethics and Public Trust shall have the authority to adopt rules of procedure regarding appeals from
the Clerk of the Board of County Commissioners.
Except as otherwise provided in subsection of the Ordinance,the validity of any action or determination of the
Board of County Commissioners or County personnel,board or committee shall not be affected by the failure of any
person to comply with the provisions of this subsection(s). (Ord.No 00-19,§ 1, 2-8-00; Ord.No 01-93,§ 1, 5-22-
01; Ord. No. 01-162, § 1, 10=23:01;"ord.'No:03=107;§1.,.5-6-03)
Pa1713 gnf1f1
Miami-Dade County's Affidavits and Declarations ' •
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MIAM0-DADS
COUNTY
I have carefully read this entire ten (10) page document entitled, "Miami-Dade County's Affidavits and
Declarations" and agree to; (1)sign an affidavit as to certain matters and(2) make a declaration as to certain
other matters. This form contains both an Affidavit form for matters requiring the entity to sign under oath and a
Declaration form for matters requiring only an affirmation or declaration for other matters.
Each section of this form must be read,and initialed indicating acceptance and/or compliance with the County's
policy related to the particular affidavit For affidavit sections that you do not believe are applicable to your
organization,please indicate this by placing"x"in the box next to N/A.
BY SIGNING AND NOTARIZING TIES PAGE YOU ARE ATTESTING TO AFFIDAVITS 1-15
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MIAMI-DADE COUNTY AFFIDAVITS SIGNATURE PAGE
By: // Z/is/n� RnF-Aac Gn,,-Ki4,..,.y' wvyVt 2 /s / 20
Signatur:I of Witness or Secretary Se`tea \ B 1 •
Signa of Affi. 1 t i "---- Ft-de.Taltaployer Identification Number
* \NcoRP ORATED:
Ti ivIM L . MoRALes '•c.4•=.-r-Y 9rn, Nil/�, -' BEACH
Printed ;II e of Affiant and Nam \-,' -ertcy' .•,'•,,O)Z-1
i oc 6_oNV'tN r 1 a>NJ CUN i
Address of Agency /
SUBSCRIBED AND SWORN TO (or affirmed) before me this /S day of F-Q60yGy, 2017
He/She is personall ji own to me or has presented as identification.
Type of identification
'!.. #
"nature of Notary Serial Number
Print or Stamp Name of Notary Expiration Date
Notary Public—State of lOrl cA :t. ' ::
?,; fat :.: MY COMMISSION#FF 155322
y'..'"�., EXPIRES:August 27,2018
r�^, �'';e o ??:. Bonded Thru Notary Public Underwriters
County of V'VI Q -Dar -
Notary Seal
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ATTACHMENT(C) Miami-Dade County Affidavits and Declarations Paee 10 of 10