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<br />ATTACHMENTE <br /> <br />JAGIBYRNE 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 CRllvHNAL 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 />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 />r1o~tJ\.t\J <;. ~~~ <br /> <br />Affiant <br /> <br />I, <br /> <br />, being first duly sworn state: <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 />0s.0(~+1041 <br />Federal Employer Identification Number (If none, Social Security) <br /> <br /> <br />Doing Business As (if same as above, leave blank) <br /> <br />\ <rio1 0 ('nl-U~~ ~~ ~tJ.!~ \~S ~ 0- ~l~ <br />Street Address City \ State Zip Code <br /> <br />"'11. MIAMI-DADE COUNTY OWNERSHIP 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 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 />FulI Legal Name <br /> <br />Address <br /> <br />Ownership <br /> <br />% <br /> <br />% <br /> <br />% <br /> <br />1 of 5 <br />2. The full legal names and business address of any other individual (other than subcontractors, <br />material men, suppliers, laborers, or lenders) who have, or will have, any interest (legal, equitable <br />