Reso 2013-2143 - Laserfiche WebLink

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ATTACHMENT E JAGBYRNE GRANT ADMINISTRATION MIAMI -DADE COUNTY AFFIDAVITS The contracting individual or entity (governmental or otherwise) shall indicate by an "X" all affidavits that pertain to this contract and shall indicate by an "N /A" all affidavits that do not pertain to this contract. All blank spaces must be filled. The MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI -DADE COUNTY EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI -DADE CRIMINAL RECORD AFFIDAVIT; DISABILITY NONDISCRIMINATION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any political subdivision or agency thereof or any municipality of this State. The MIAMI -DADE FAMILY LEAVE AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies or the State of Florida or any political subdivision or agency thereof, it shall, however, pertain to municipalities of the State of Florida. All other contracting entities or individuals shall read carefully each affidavit to determine whether or not it pertains to this contract. C,ew aH S • Colp I c�,f , being first duly sworn state: Affiant The full legal name and business address of the person(s) or entity contracting or transacting business with Miami -Dade County are (Post Office addresses are not acceptable): lrS- D-7 gcf ta4-7 Federal Employer Identification Number (If none, Social Security) Name of Entity, IAdividual(s), Partners, or Corporation ing Business As (if same as above, leave blank) 1 of o C.ol l el-, t Ave. S u 011 %G!z rL- 331 U 6 Street Address / City State Zip Code I. MIAMI -DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2 -8.1 of the County Code) 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 municipals y, of this State. All such names and addresses are (Post Office addresses are not acceptable): Full Legal Name Address Ownership 1 of 5