STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D__-_Signed.pdf
PDF 292 KB Posted
- Attached to
- Agency Administered OH|CTR030774
- Contract number
- CTR030774
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D & 2022-02D, addressing the expenditure of public funds on offshore services and response to Russia's actions. The form is completed by a contractor, with the principal business location at 3075 Adeline St., Ste #155 in Berkeley, CA 94703. Two subcontractors are listed: Eightfold Way Consultants (1537 Euclid Ave., Berkeley, CA 94708) and Economic Consultants Oregon, LTD. (920 SW 6th Ave., Suite 1400 Portland, OR 97204).
The form affirms that all services and state data will be located in the United States, specifically at the contractor's Berkeley, CA address and the subcontractors' locations in Berkeley and Portland. The document requires the contractor to disclose any changes in service locations before, during, and after contract execution, with the understanding that the state retains the right to immediately terminate the contract unless a waiver is obtained. The form was signed by Marcie Roth, Executive Director & CEO, on July 15, 2025, certifying compliance with the specified executive orders regarding offshore services and restrictions on Russian institutions or companies.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| executed_Contract_CTR030774_World_Institute_on_Disability.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
STANDARD AFFIRMATION AND DISCLOSURE FORM
EXECUTIVE ORDERS 2019-12D & 2022-02D
EO2019-12D & 2022-02D Form (rev. 3 2022)
Governing the Expenditure of Public Funds on Offshore Services & Response to Russia’s Unjust War
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 all the name(s) and location(s) where services under this contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
2. Location(s) where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
3. Location where state data will be located, by Contractor:
(Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
STANDARD AFFIRMATION AND DISCLOSURE FORM
EXECUTIVE ORDERS 2019-12D & 2022-02D
EO2019-12D & 2022-02D Form (rev. 3 2022)
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 subcontractors before, during, and after execution of any Contract with the State. Contractor agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside of the United States.
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 Department and is incorporated therein.
By: ____________________________________
Print Name: _____________________________
Title: ___________________________________
Date: ___________________________________
File details come from the government source that posted it. Updated .