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<br />ATTACHMENT D <br /> <br />MIAMI-DADE COUNTY AFFIDAVITS <br /> <br />The contracting individual or entity (governmental or otherwise) shaH indicate by an "X" all affidavits that pertain <br />to this contract and shall indicate by an "N/A" all affidavits that do not pertain to this contract. All blank spaces must be <br />filled. <br /> <br />i .; <br />; ; <br /> <br />The MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY <br />EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-DADE CRIMINAL RECORD AFFIDAVIT; DISABILITY <br />NONDISCRIMINA TION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT shall not pertain to contracts <br />with the United States or any of its departments or agencies thereof, the State or any political subdivision or agency thereof <br />or any municipality of this State. The MIAMI-DADE FAMILY LEAVE AFFIDAVIT shall not pertain to contracts with <br />the United States or any of its departments or agencies or the State of Florida or any political subdivision or agency thereof; <br />it shall, however, pertain to municipalities of the State of Florida. All other contracting entities or individuals shall read <br />carefully each affidavit to determine whether or not it pertains to this contract. <br /> <br />I, <br /> <br />, being ftrst duly sworn state: <br /> <br /> <br />Affiant <br /> <br />The full legal name and business address of the person(s) or entity contracting or transacting business with Miami-Dade <br />County are (Post Office addresses are not acceptable): <br /> <br />Federal Employer Identiftcation Number (If none, Social Security) <br /> <br />Name of Entity, Individual(s), Partners, or Corporation <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br />Street Address <br /> <br />City <br /> <br />State <br /> <br />Zip Code <br /> <br />1. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) <br /> <br />1. <br /> <br />If the contract or business transaction is with a corporation, the full legal name and business <br />address shall be provided for each officer and director and each stockholder who holds directly <br />or indirectly ftve percent (5%) or more of the corporation's stock. If the contract or business <br />transaction is with a partnership, the foregoing information shall be provided for each partner. If <br />the contract or business transaction is with a trust, the full legal name and address shall be <br />provided for each trustee and each beneftciary. The foregoing requirements shall not pertain to <br />contracts with publicly-traded corporations or to contracts with the United States or any <br />department or agency thereof, the State or any political subdivision or agency thereof or any <br />municipality of this State. All such names and addresses are (Post Office addresses are not <br />acceptable): <br /> <br />~.. <br /> <br />Full Legal Name <br /> <br />Address <br /> <br />Ownership <br /> <br />% <br /> <br />% <br /> <br />% <br /> <br />;/00 <br /> <br />PagelofS <br />