04-Affirmation and Disclosure Form_3-4-22.pdf
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- Solicitation number
- SRC0000028626
- Issued by
- Stark County, Ohio
About this file
The Affirmation and Disclosure Form is a document associated with the Ohio Department of Natural Resources (ODNR) for the Tippit Marsh Embankment Stabilization project at Pickerel Creek Wildlife Area. The form requires contractors to disclose and affirm the locations where services will be performed, where state data will be stored, and to acknowledge Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions. Contractors must provide detailed information about their principal business location, service performance locations, and subcontractor details, with failure to provide complete information potentially resulting in contract non-award.
The form emphasizes ongoing transparency, requiring contractors to immediately disclose any changes in service or data location before, during, and after contract execution. The State retains the right to terminate the contract if services are moved outside the United States without a signed waiver. Contractors must acknowledge their understanding of these terms by signing the form, which becomes an integral part of any potential contract with the State. The document, revised in March 2022, serves as a critical compliance mechanism to ensure contractors adhere to state regulations regarding service delivery, data management, and geopolitical restrictions.
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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 .