04-Affirmation and Disclosure Form_3-4-22.pdf
PDF 85 KB Posted
- Attached to
- PCI FHC dialysis water system replacement
- Solicitation number
- SRC0000034851
- Issued by
- Ross County, Ohio
About this file
Summary
This is an Affirmation and Disclosure Form (Revision 3/22) required by a state contracting authority. The form mandates that contractors affirm their understanding of 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 stored, including information for any subcontractors used. The form requires contractors to identify up to five subcontractor locations for state data storage and service performance locations.
Contractors and their subcontractors are obligated to notify the state immediately of any changes or shifts in service location before, during, or after contract execution. Failure to provide complete location information may result in no award. 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 form must be signed by a duly authorized representative of the contractor, including the signatory's printed name, title, and date of execution. This form is incorporated into and becomes part of any resulting contract with the state.
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Other files
| File | Type | Posted |
|---|---|---|
| EO+2019-12D.pdf | ||
| PCI Dialysis Water System Replacement V1.pdf | ||
| EO_2022-02D (1).pdf | ||
| A ODRC INSTRUCTIONS TERMS AND CONDITIONS FOR BIDDING.pdf |
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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 .