04-Affirmation and Disclosure Form_3-4-22 Fill In.pdf
PDF 91 KB Posted
- Attached to
- PWC SW M East Fork Mini Skid
- Solicitation number
- SRC0000018567
- Issued by
- Clermont County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local contract opportunity in Ohio. The form requires the contractor to disclose the location(s) where services will be performed and where state data will be located, including any subcontractors. The contractor must affirm that they have read and understand the applicable Executive Orders regarding the prohibitions of offshore services, locating State data offshore, or purchasing from Russian institutions or companies. The contractor must notify the State immediately of any change or shift in the location of their services.
The related state and local contract opportunity is for the purchase of a new 2024 Vermeer S925TX Mini Skid Steer with accessories, including a Vermeer SC802 Stump Grinder, for the East Fork State Park in Clermont County, Ohio. The estimated completion/delivery date for this equipment is May 31st, 2024. The contract specifications and scope of work are detailed in the document, including the required product features and quantities.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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:
| AFFIRMATION AND DISCLOSURE FORM: |
| Address: |
| City State Zip: |
| Name: |
| Address City State Zip: |
| Name_2: |
| Address City State Zip_2: |
| Address_2: |
| City State Zip_2: |
| Name_3: |
| Address City State Zip_3: |
| Name_4: |
| Address City State Zip_4: |
| Address_3: |
| City State Zip_3: |
| Name_5: |
| Name_6: |
| Name_7: |
| Name_8: |
| Name_9: |
| Address City State Zip_5: |
| Address City State Zip_6: |
| Address City State Zip_7: |
| Address City State Zip_8: |
| Address City State Zip_9: |
| Contractor: |
| Print Name: |
| Title: |
| Date: |
File details come from the government source that posted it. Updated .