4_Standard Affirmation & Disclosure Form_fillable PDF Form (1).pdf

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Attached to
PWC Headlands Beach Automatic Gate Repair State and local contract opportunity
Solicitation number
SRC0000034461
Issued by
Lake County, Ohio

About this file

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form related to state contracting requirements, designed to ensure transparency about service locations and compliance with Executive Orders. The form requires contractors to disclose the principal business locations of their company and any subcontractors, specifically listing the addresses where services will be performed and where state data will be accessed, tested, maintained, backed-up, or stored. Contractors must affirm that they understand and will comply with prohibitions on offshore services, locating state data offshore, and purchasing from Russian institutions or companies.

The form mandates that contractors have a continuing obligation to disclose any changes in service locations before, during, and after contract execution, with the state retaining the right to terminate the contract if services are performed or data is located outside the United States without a signed waiver. Contractors must provide comprehensive location details for their own operations and any subcontractors, including specific addresses for business locations, service performance sites, and data management facilities. The document emphasizes strict geographical restrictions and requires an authorized company representative to sign, acknowledging understanding and compliance with these location and data sovereignty requirements.

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Version 5/24 Page 1 of 2

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.

The Contractor shall provide the name(s) and location(s) where all services under this Contract will be performed and where State data will be located in the spaces provided below or by attachment. If the Contractor will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.

Contractor Name: ___________________________ Contract Number:

1. Principal business location of Contractor:

(Address) (City, State, Zip)

Name(s)/Principal business location(s) of subcontractor(s):

(Name) (Address, City, State, Zip)

2. Location(s) where services will be performed by Contractor:

Name(s)/Location(s) where services will be performed by subcontractor(s):

Version 5/24 Page 2 of 2

3. Location(s) where any State data associated with any of the services Contractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:

Name(s)/Location(s) where any State data associated with any of the services any subcontractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:

Contractor also 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 to notify the State immediately of any such change or shift in location of its services. The State has the right to terminate the contract if any services are performed or State data is located outside of the United States unless a duly signed waiver from the State has been attained.

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: __________________________________ Authorized Contractor Signature

Print Name: ___________________________

Title: __________________________________

Date: __________________________________

Contractor Name:
Contract Number:
Address:
City State Zip:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Address_3:
City State Zip_3:
Name_3:
Name_4:
Address City State Zip_3:
Address City State Zip_4:
Address_4:
City State Zip_4:
Address_5:
City State Zip_5:
Name_5:
Name_6:
Name_7:
Name_8:
Name_9:
Address City State Zip_5:
Address City State Zip_6:
Address City State Zip_7:
Address City State Zip_8:
Address City State Zip_9:
Print Name:
Title:
Date:

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