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<br />ATTACHMENT D <br /> <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 OWNERSHIP DISCLOSURE AFFIDAVIT; MIAMI-DADE COUNTY <br />EMPLOYMENT DISCLOSURE AFFIDAVIT; MIAMI-DADE CRIMINAL RECORD AFFIDAVIT; <br />DISABILITY NONDISCRIMINA nON 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 F AMIL Y 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 determine <br />whether o'iot it pertains to this contract. <br /> <br />I, AItJ, /llall S. E~kll/J , being first duly sworn state: <br />Affiant I <br /> <br />The full legal name and business address 0 f the p erson( s) 0 r entity contracting 0 r transacting business with <br />Miami-Dade County are (Post Office addresses are not acceptable): <br /> <br />t5--01RI~~'1 <br />Federal Employer Identification Number (If none, Social Security) <br /> <br />e. tJf ~1I(J/J. ~/~ <br />Name ofE ty, Individual(s), Partne , or Corporation <br /> <br />(Zf]c.k <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br /> <br />FL ,%..!J){,O <br />Zip Code <br /> <br />_ I. MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDAVIT (See, 2-8, I 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 mdirectly <br />. } I/} five percent (5%) or more of the corporation's stock. If the contract or business transaction is with a <br />JU' / h partnership, the foregoing information 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 />1 of 5 <br />