04-Affirmation_and_Disclosure_Form_MANCI_04152025.pdf
PDF 1 MB Posted
- Attached to
- Agency Administered OH|407-25-4523
- Contract number
- 407-25-4523
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form for a state contract, specifically involving the Ohio Department of Rehabilitation and Correction. The contractor is located in Dublin, Ohio, with services to be performed at the Marion Correctional Institution (MANCI) in Mansfield, Ohio. The form affirms the contractor's compliance with Executive Orders regarding offshore services, state data location, and purchasing restrictions, particularly those related to Russian institutions or companies.
The form indicates no subcontractors will be used, and no state data will be stored offshore. The contractor, represented by Jamal Naiyer in the role of Imam, has signed the document with an effective date of 04/15/2025. The form emphasizes the contractor's ongoing 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.
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Text version
AFFIRMATION AND DISCLOSURE FORM
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 ofbusinessofContractor:
4924 Sterling Woods Ct (Address)
Dublin, Ohio 43016 (City, State, Zip)
Name/Principal location ofbusiness ofsubcontractor(s):
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
Marion Correctional Institution (Address)
Marion. Oh 43301-0057 (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
Rev. 3/22 Page 1 of2
MANCIMANCI, 1150 North Main Street Mansfield, OH 44903
3. Location where state data will be located, by Contractor:
NIA
(Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
NIA
(Name) (Address, City, State, Zip)
Contractor affirms, understands, and agrees that Contractor and its subcontractors are under a duty to disclose to the State anychange 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 Statéand is incorporated therein.
By:
Contractor
Jamal NaiyerPrint Name:
Title:
Date:
Imam
Rev.3/22 Page2 of 2
04/15/2025
File details come from the government source that posted it. Updated .