04-Affirmation and Disclosure Form_3-4-22.pdf
PDF 80 KB Posted
- Attached to
- Polaris Ranger UTV State and local contract opportunity
- Solicitation number
- SRC0000031063
- Issued by
- Van Wert County, Ohio
About this file
The document is an Affirmation and Disclosure Form, revision 3/22, designed for a state government contract that requires contractors to provide detailed information about their business locations and service performance sites. The form mandates that contractors affirm their understanding of Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions or companies. Contractors must comprehensively disclose the principal business location, service performance locations, and data storage locations for both their own organization and any subcontractors.
The form emphasizes ongoing transparency, requiring contractors to immediately notify the state of 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 performed outside the United States without a signed waiver. By executing this form, the contractor acknowledges that it is a binding part of any potential state contract and agrees to comply with all specified location and disclosure requirements. The form includes signature lines for the contractor's authorized representative to print their name, title, and date of acknowledgment.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| OPERS Independent Contractor Form_fillable PDF Form.pdf | ||
| Ohio Buys Request for Quote Polaris Ranger.pdf | ||
| Standard_T_C_04-10-23.pdf | ||
| Ohio Buys Information.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 .