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<br />ATTACHMENT 0 <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 otherwis-e) shall indicate by an "X" all affidavits <br />that pertain to this contract and shall indicate by an "NI 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 AFFIDA VIr; <br />DISABILITY NONDISCRIMINATION AFFIDA VIr; and the PROJECT FRESH START AFFIDA VIr 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 />AFFIDA VIT 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 or not it pertains to this contract. <br /> <br />rk -~ <br />/1 ' . <br />I, ./ '{i/'/! 0/7 :J. -L;-!t/ Co tJ , being first duly sworn state: <br />Affiant I <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 no.t,acceptable): <br /> <br />& :; -D'f,j I L' ;j 1 <br />Federal Employer Identification Number (If none, Social Security) <br /> <br />/, / (", /) ~ ) /"" <br />cilll I) JU(hlL l:.,'/t:j .J)eLJLI/ <br />Name of Entity, Individual(s, artners, or Corporation <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br />'7 ~ ;;' J/ 'f --I' ,n ,,'.n' ../J , / <br />. _~)///fU: /;//{'///;", L ,7ft..',// <br />Street Address City <br /> <br />(7 'I. 1/ <br />J/II/I// ,.:J/..-::'/J <br />State' <br /> <br />I , /,/' ')0'" / ) <br />L!Jcd/J! ../1 /{/i/[ {./ <br />Zip Code <br /> <br />_I. ,MIAMI-DADE COUNTY OWNERSHIP DISCLOSURE AFFIDA VIr (Sec. 2-8.1 of the County Code) <br /> <br />lVil <br /> <br />I. 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 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 />lof5 <br />