04-Affirmation_and_Disclosure_Form_3-4-22-CRC__1_.pdf
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- Attached to
- Agency Administered OH|429-26-3365
- Contract number
- 429-26-3365
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form revised in March 2022, involving a contractor located in Dublin, Ohio, and pertaining to services to be performed at correctional facilities in Ohio, specifically the Marion Correctional Institution and the Correctional Reception Center in Orient. The form requires the contractor to affirm understanding of Executive Orders regarding offshore services, data location, and purchasing restrictions.
The contractor, Jamal Naiyer with the title of Imam, has indicated that services will be performed at the specified correctional facilities, with no subcontractors involved. The form emphasizes the contractor's obligation to disclose any changes in service locations before, during, and after contract execution, with the state retaining the right to immediately terminate the contract if services are moved outside the United States without a signed waiver. The document is signed and dated for a period ending 05/02/2025, though specific contract details, pricing, and precise scope of services are not elaborated in this disclosure form.
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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):
4924 Sterling Woods Ct Dublin, Ohio 43016
N/A
N/A
Marion Correctional Institution Marion. Oh 43301-0057
N/A
N/A
Orient, Ohio 43146Correctional Reception Center
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:
N/A
N/A
N/A
N/A
N/A
N/A
Imam
06/06/2023
Jamal Naiyer
05/02/2025
File details come from the government source that posted it. Updated .