04-Affirmation_and_Disclosure_Form_3-4-22-MCI.pdf
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- Attached to
- Agency Administered OH|413-24-3305
- Contract number
- 413-24-3305
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state contract, specifically involving Marion Correctional Institution in Marion, Ohio. The contractor, located at 4924 Sterling Woods Ct in Dublin, Ohio, has completed this form to affirm compliance with Executive Orders regarding offshore services, data location, and purchasing restrictions. The form requires disclosure of business locations, service performance sites, and potential subcontractor information, with the contractor indicating no subcontractors will be used for this engagement.
The document shows the contract services will be performed at Marion Correctional Institution, with the contractor (Jamal Naiyer, with the title of Imam) signing and dating the form on 05/07/2025. The form emphasizes the contractor's obligation to disclose any changes in service locations to the state, with the understanding that the state retains the right to immediately terminate the contract if services are moved outside the United States without proper authorization. No specific details about the exact goods or services, pricing, or contract value are provided in this disclosure document.
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Other files
| File | Type | Posted |
|---|---|---|
| AAPV_-_202406-15472_-_Jamal_Naiyer.pdf | ||
| BWC_July_2025_to_June_2026.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):
4924 Sterling Woods Ct Dublin, Ohio 43016
N/A
N/A
Marion Correctional Institution Marion. Oh 43301-0057
N/A
N/A
Marion, Ohio 43301Marion Correctional Institution
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:
N/A
N/A
N/A
N/A
N/A
N/A
Imam
06/06/2023
Jamal Naiyer
05/07/2025
File details come from the government source that posted it. Updated .