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

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Attached to
PWC Mosquito LE Office Renovation
Solicitation number
SRC0000036676
Issued by
Ohio

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Written by GovTribe AI ·

This is an Affirmation and Disclosure Form required by the State of Ohio for the PWC Mosquito Lake State Park Law Enforcement Office Renovation project. The form serves as a compliance document for contractors bidding on or executing state contracts and requires contractors to affirm their understanding of Executive Orders prohibiting offshore services, offshore data location, and purchases from Russian institutions or companies. Contractors must provide comprehensive disclosure of their principal business location, all subcontractor names and locations, service performance locations, and any locations where state data will be accessed, tested, maintained, backed-up, or stored. The form applies to the renovation project at Mosquito Lake State Park, which aims to accommodate two Law Enforcement offices within the renovated facility.

The disclosure requirements mandate that contractors identify all geographic locations where work will be performed and where state data will be housed, with the explicit requirement that all services and data must remain within the United States unless the contractor obtains a signed waiver from the State. Contractors are required to immediately notify the State of any changes or shifts in service locations before, during, or after contract execution. The State reserves the right to terminate any contract if services are performed or state data is located outside the United States without proper authorization. The form must be signed by an authorized representative of the contractor and becomes an incorporated component of any resulting contract with the State of Ohio.

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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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