Laserfiche WebLink
<br />DEPARTMENT OF HUMAN SERVICES <br />BYRNE GRANT ADMINISTRATION <br /> <br />MIAMI-DADE COUNTY AFFIDAVITS <br /> <br />The contracting individual or entity (governmental or otherwise) shall indicate by an "X" all affidavits <br />that pertain to this contract and shall indicate by an ''N/A'' all affidavits that do not pertain to this contract. All <br />blank spaces must be filled. <br /> <br />The MIAMI-DADE COUNTY OWNERSlllP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY <br />EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-DADE CRIMINAL RECORD AFFIDAVIT; <br />DISABILITY NONDISCRIMINATION AFFIDAVIT; and the PROJECT FRESH START AFFIDAVIT shall <br />not pertain to contracts with the United States or any of its departments or agencies thereof, the State or any <br />political subdivision or agency thereof or any municipality of this State. The MIAMI-DADE FAMILY LEAVE <br />AFFIDAVIT shall not pertain to contracts with the United States or any of its departments or agencies or the <br />State of Florida or any political subdivision or agency thereof; it shall, however, pertain to municipalities of the <br />State of Florida. All other contracting entities or individuals shall read carefully each affidavit to detennine <br /> <br />IW,heilier n it ~to ~t . ct._ <br /> <br />'" , being first duly sworn state: <br /> <br />/ <br /> <br />The full legal name and business address of the person(s) or entity contracting or transacting business with <br />Miami-Dade County are (Post Office addresses are not acceptable): <br /> <br />& 5/ D7fLjIoL/7 <br /> <br />Federal Employer Identification Number (If none, Social Security) <br /> <br />CII~ of SUIJnfJ Isles 1x!Qd1 <br /> <br />Name of Entity, Individual(s), Partners, or Corporation <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br />17D7D {!()/lliJJ f!(r!- ~r;UI)I)!J ..ISles 73eClch ; tl 33Jt..{J <br />Street Address City State ' Zip Code <br /> <br />_ I. MIAMI-DADE COUNTY OWNERSlllP DISCLOSURE AFFIDAVIT (Sec. 2-8.1 of the County Code) <br /> <br />1. If the contract or business transaction is with a corporation, the full legal name and business address <br />shall be provided for each officer and director and each stockholder who holds directly or indirectly <br />five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a <br />partnership, the foregoing infonnation shall be provided for each partner. If the contract or business <br />transaction is with a trust, the full legal name and address shall be provided for each trustee and each <br />beneficiary. The foregoing requirements shall not pertain to contracts with publicly traded <br />corporations or to contracts with the United States or any department or agency thereof, the State or <br />any political subdivision or agency thereof or any municipality of this State. All such names and <br />addresses are (Post Office addresses are not acceptable): <br /> <br />Full Legal Name <br /> <br />Address <br /> <br />Ownership <br /> <br />% <br /> <br />% <br /> <br />% <br /> <br />lof5 <br />