2025_2-Standard_Affirmation_and_Disclosure_Form.pdf
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- Attached to
- Agency Administered OH|CTR031072
- Contract number
- CTR031072
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form dated March 2022, involving a contractor based in Cincinnati, Ohio. The form requires the contractor to disclose locations where services will be performed and state data will be located, while affirming compliance with Executive Orders regarding offshore services, state data location, and restrictions on purchasing from Russian institutions or companies.
The contractor, represented by Rabbi Menachem Kalmanson, indicates their principal business location is 7256 Laurel Oak Lane in Cincinnati, OH 45237, with service performance and state data location at 3791 State Route 63 in Lebanon, OH 45036. No subcontractors are listed (marked as "N/A"), and the form includes an agreement that the contractor will immediately notify the state of any changes in service or data location. The document is signed and dated for a period ending 7-3-2025, with the contractor affirming understanding of the state's right to terminate the contract if services are performed outside the United States without a signed waiver.
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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 Contract
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:
7256 Laurel Oak Lane Cincinnati, OH 45237
N/A N/A
Lebanon, OH 45036 devor Typewritten Text 3791 State Route 63 devor Typewritten Text Lebanon, OH 45036 devor Typewritten Text 3791 State Route 63
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:
N/A N/A
Rabbi Menachem Kalmanson
Rabbi
7-3-2025 devor Typewritten Text
| 2025-07-03T21:59:54-0400 | |
| Menachem Kalmanson |
File details come from the government source that posted it. Updated .