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 for contractors bidding on snow removal services at six northeastern Ohio state parks (Punderson, Geneva, Mosquito Lake, West Branch, Lake Milton, and Nelson-Kennedy). The form requires contractors to affirm compliance with Executive Orders prohibiting offshore services, offshore data storage, and purchases from Russian institutions or companies. Contractors must disclose the principal business locations of the contractor and any subcontractors, all locations where services will be performed, and all locations where state data will be accessed, tested, maintained, backed up, or stored. The contract term runs through April 30, 2027, with potential mutual renewals not exceeding 36 months total. Contractors are obligated to notify the State immediately of any changes or shifts in service locations and must maintain all operations within the United States unless a signed waiver is obtained from the State.
The form establishes that contractors and subcontractors have a continuing duty to disclose location changes before, during, and after contract execution. The State reserves the right to terminate the contract if any services are performed or state data is located outside the United States without prior written authorization. Contractors must provide detailed information for multiple subcontractors if applicable, including names and addresses. An authorized representative of the contractor must sign the form, certifying that they are duly authorized to execute the affirmation and that the form is incorporated into any resulting contract with the State. No specific pricing information, set-asides, insurance requirements, or budgetary details are addressed in this particular form, as it functions solely as a compliance and disclosure 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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