01-Affirmation_and_Disclosure_Form_3-4-22.pdf
PDF 85 KB Posted
- Attached to
- ODRC – Rigging and Moving Services for 2 Industrial Plastic Bag Machines - OPI LoCI Bag Shop -ITB DRC260127
- Solicitation number
- SRC0000037138
- Issued by
- Mahoning County, Ohio
About this file
Affirmation and Disclosure Form for Ohio ODRC Rigging and Moving Services Contract
This is an Affirmation and Disclosure Form (Revision 3/22) submitted by the contractor for the Ohio Department of Rehabilitation and Correction (ODRC) contract ITB DRC260127, which involves rigging and moving services for two industrial plastic bag machines at the London Correctional Institution. The form requires the contractor to disclose all locations where services will be performed, subcontractor information, and data storage locations. The contractor must affirm understanding of Executive Orders prohibiting offshore service performance, state data location outside the United States, and purchasing from Russian institutions or companies. Failure to provide complete location information may result in no contract award.
The form establishes that the contractor and all subcontractors have a continuing duty to immediately notify the state of any changes or shifts in service locations before, during, and after contract execution. The state retains the right to immediately terminate the contract if services are performed outside the United States without a duly signed waiver from the state. The contractor's authorized representative must sign the form, certifying that they have read and understood that the Affirmation and Disclosure Form constitutes a material part of any resulting contract with the state and is incorporated therein.
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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 .