4_Standard Affirmation & Disclosure Form_fillable PDF Form (1).pdf
PDF 104 KB Posted
- Attached to
- PWC NE District Parks Snow Removal
- Solicitation number
- SRC0000035235
- Issued by
- Geauga County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Natural Resources (ODNR), Division of Parks and Watercraft, for the PWC NE District Parks Snow Removal contract opportunity. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore State data location, and purchases from Russian institutions or companies. Contractors must disclose the principal business location of the contractor and all subcontractors, identify all locations where services will be performed, and specify where any State data will be accessed, tested, maintained, backed up, or stored. The form requires contractors to commit to notifying the State immediately of any changes or shifts in service locations before, during, and after contract execution. The contract term runs through April 30, 2027, with potential mutual renewals not exceeding 36 months total for the on-demand snow removal services spanning six northeastern Ohio state parks in Geauga County and surrounding areas, including Punderson, Geneva, Mosquito Lake, West Branch, Lake Milton, and Nelson-Kennedy State Parks.
The Affirmation and Disclosure Form serves as a binding contractual document incorporated into any agreement with the State and must be executed by an authorized contractor representative. The State reserves the right to terminate the contract if any services are performed or State data is located outside the United States unless a duly signed waiver has been obtained. Contractors and subcontractors are under a continuous duty to disclose location changes, and all service locations must remain within the United States. The form requires detailed information regarding subcontractor names and locations, with multiple blank entries provided for contractors utilizing multiple subcontractors. This disclosure mechanism ensures State oversight and compliance with geographic and data security requirements established by Ohio Executive Orders.
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Text version
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: __________________________________
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