01-Affirmation_and_Disclosure_Form_3-4-22.pdf
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- Solicitation number
- SRC0000030449
- Issued by
- Ross County, Ohio
About this file
This document is an Affirmation and Disclosure Form designed for a state government contract, requiring contractors to provide detailed information about their business locations and service performance sites. The form mandates that contractors affirm their understanding of Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions. Contractors must disclose the principal business location, locations where services will be performed, and sites where state data will be located, including information for any potential subcontractors.
The form emphasizes a strict requirement for transparency regarding service and data locations, with contractors obligated to immediately notify the state of any changes in service locations before, during, or after contract execution. The state retains the right to terminate the contract if services are performed outside the United States without a signed waiver. By executing this form, the contractor acknowledges that it is a binding part of any potential contract with the state, and the authorized representative must sign, print their name, provide their title, and date the document.
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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 .