4_Standard Affirmation & Disclosure Form_fillable PDF Form (1).pdf
PDF 104 KB Posted
- Attached to
- PWC Mosquito Yurt Decking Replacement State and local contract opportunity
- Solicitation number
- SRC0000034402
- Issued by
- Trumbull County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the State of Ohio for the PWC Mosquito Yurt Decking Replacement project at Mosquito Lake State Park in Trumbull County. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore services performance, offshore data location, and purchases from Russian institutions or companies. Contractors must disclose all principal business locations, service performance locations for both the contractor and any subcontractors, and all locations where State data will be accessed, tested, maintained, backed up, or stored. The project involves replacing decking, railing, awning/cover, spindles, and lattice for two yurts using commercial-grade composite or wood materials, with work to be completed between November 1st and December 31st, 2025. A mandatory site visit must be conducted prior to bidding, and proposals are due November 3rd, 2025. The contract will be awarded to the lowest responsive and responsible bidder and is valid through June 30, 2026.
Contractors and their subcontractors must certify that all services will be performed and all State data will be located within the United States, 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 State waiver. Contractors are under a continuous duty to disclose any changes or shifts in service location before, during, and after contract execution and must notify the State immediately of any such changes. The form must be executed by an authorized company representative and becomes incorporated into any resulting contract. No specific budget range or pricing terms are detailed in the disclosure form itself, as it serves solely as a compliance and location transparency document separate from pricing submissions.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| RFQ Yurt Patio Decking 2025.docx | DOCX document | |
| OhioBuys+Fact+Sheet+for+Bidders_Suppliers.pdf | ||
| 3_ DAS Terms and Conditions.pdf | ||
| 1_Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| 1_Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| 3_ DAS Terms and Conditions.pdf | ||
| 4_Standard Affirmation & Disclosure Form_fillable PDF Form (1).pdf | ||
| OhioBuys+Fact+Sheet+for+Bidders_Suppliers.pdf | ||
| RFQ Yurt Patio Decking 2025.docx | DOCX document |
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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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