04-Affirmation_and_Disclosure_Form_3-4-22.pdf
PDF 80 KB Posted
- Attached to
- Agency Administered OH|CTR032728
- Contract number
- CTR032728
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form (Revision 3/22) designed to capture location details for contractors performing services for a state government contract. The form requires contractors to disclose the principal business location, service performance locations, and data storage locations for both the primary contractor and any potential subcontractors, with a specific focus on compliance with Executive Orders regarding offshore services and restrictions on working with Russian institutions or companies.
The form mandates that contractors provide transparency about their operational locations and affirm their understanding that they must immediately notify the state of any changes in service or data location. The document includes provisions that give the state the right to terminate the contract if services are to be performed outside the United States without a signed waiver. The form is meant to be incorporated as part of any contract between the contractor and the state, with the contractor's authorized representative required to sign and acknowledge the terms, demonstrating their commitment to the disclosed location information and compliance requirements.
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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 .