04_-_Affirmation_and_Disclosure_Form_3-4-22_Fillable_PDF_86_.pdf
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- Attached to
- Agency Administered OH|CTR031043
- Contract number
- CTR031043
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state contract, signed by an authorized representative from an organization involved in Incarceration Ministries. The form is designed to affirm compliance with Executive Orders regarding offshore services, data location, and purchasing restrictions, specifically addressing prohibitions on performing services outside the United States and purchasing from Russian institutions. The contractor's primary business location is at 100 East 8th St in Cincinnati, OH 45202, with a service location at 3791 OH Route 63 in Lebanon, OH 45036.
The form does not provide specific details about the contracted goods or services, pricing terms, or contract amounts. However, it emphasizes the contractor's obligation to disclose any changes in service locations before, during, and after contract execution. The document is signed by Marty Arlinghaus, Director of the Office of Incarceration Ministries, with an effective date of 6/26/2025. The form underscores the state's right to immediately terminate the contract if services are performed outside the United States without a signed waiver, highlighting the strict geographical and operational requirements of the contract.
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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:
3. Location where state data will be located, by Contractor:
Docusign Envelope ID: 081802BB-008E-48E8-BBB8-459308267171
Cincinnati, OH 45202
Lebanon, OH 45036
Cincinnati, OH 45202
3791 OH Route 63
100 East 8th St
100 East 8th St
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:
Docusign Envelope ID: 081802BB-008E-48E8-BBB8-459308267171
Marty Arlinghaus
6/26/2025
Director, Office of Incarceration Ministries
| 2025-06-26T19:11:28-0700 | |
| Digitally verifiable PDF exported from www.docusign.com |
File details come from the government source that posted it. Updated .