04-Affirmation_and_Disclosure_Form_3-4-22.pdf
PDF 403 KB Posted
- Attached to
- Competitive Selection OH|DOT00526-14
- Contract number
- DOT00526-14
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form, revised in March 2022, completed by a contractor located at 3427 E Dublin Granville Rd in Westerville, Ohio 43081. The form requires the contractor to affirm understanding of Executive Orders related to prohibitions on offshore services, offshore data storage, and purchasing from Russian institutions or companies. The contractor is disclosing their principal business location and service performance locations, which in this case are the same address in Westerville, Ohio.
The form indicates that the contractor, represented by Lindsey Rice in the role of Operations Manager, has no subcontractors and will perform all services and data storage at their Westerville, Ohio location. The contractor agrees to immediately notify the State of any changes in service or data location and understands that the State can terminate the contract if services are moved outside the United States without a signed waiver. The form was signed on 09/08/2025 and is intended to be incorporated into any potential contract with the State.
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Other files
| File | Type | Posted |
|---|---|---|
| Signature.pdf | ||
| 005-26.pdf | ||
| 005-26_Pricing_08_22_25_Russell_Tree_Experts_updated.xlsx | XLSX spreadsheet |
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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):
3427 E Dublin Granville Rd Westerville, OH 43081
N/A
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:
Lindsey Rice
Operations Manager
09/08/2025
File details come from the government source that posted it. Updated .