04 - Affirmation and Disclosure Form_3-4-22_Fillable PDF (2).pdf

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:

3. Location where state data will be located, by Contractor:

Rev. 3/22 Page 2 of 2

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: