01-Affirmation_and_Disclosure_Form_3-4-22.pdf
PDF 85 KB Posted
- Attached to
- DRC260111-DRC OPI - Embosser Roll for Toilet Paper Manufacturing Machine at the OPI Toilet Tissue Shop
- Solicitation number
- SRC0000036205
- Issued by
- Belmont County, Ohio
About this file
This is an Affirmation and Disclosure Form (Rev. 3/22) required by a state agency as part of the contract bidding process. The form mandates that contractors affirm compliance with Executive Orders prohibiting the performance of offshore services, locating state data offshore, or purchasing from Russian institutions or companies. Contractors must disclose the principal location of their business, all locations where services will be performed, and all locations where state data will be located. The form requires identification of any subcontractors and their respective service and data locations. Contractors must provide this information in designated spaces or by attachment, with failure to disclose potentially resulting in no award of the contract.
Contractors and their subcontractors are under a continuing duty to disclose any changes or shifts in service locations or data locations before, during, and after contract execution and must notify the state immediately of any such changes. The state retains the right to immediately terminate the contract if services are performed outside the United States unless the contractor obtains a duly signed waiver from the state. The form must be executed by a duly authorized representative of the contractor, who acknowledges that the Affirmation and Disclosure Form constitutes part of and is incorporated into any contract entered into with the state.
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Text version
AFFIRMATION AND DISCLOSURE FORM
Rev. 3/22 Page 1 of 2
Contractor affirms that Contractor has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies.
Contractor shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate “Not
Applicable” in the appropriate spaces.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
Contractor affirms, understands, and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the
State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained to perform the services outside the United States.
On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and
Disclosure Form and have read and understand that this form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.
By:
Contractor
Print Name:
Title:
Date:
File details come from the government source that posted it. Updated .