Affirmation_and_Disclosure__2___2_.pdf
PDF 161 KB Posted
- Attached to
- Competitive Selection OH|DOT10226-3
- Contract number
- DOT10226-3
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form for Dynamic Surface Applications, Ltd., a contractor doing business with the State of Ohio. The form addresses compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing services from Russian companies or institutions. The contractor affirms that all services will be performed within the United States, specifically in Ohio, with its principal business location at 373 Village Road in Pennsdale, PA. No subcontractors are indicated as part of this contract.
The document does not provide specific details about the goods or services being contracted, nor does it outline pricing terms, set-asides, or contract amounts. The primary focus is on ensuring that the contractor will not perform any services outside the United States and will not allow state data to be accessed or stored remotely outside the country without a signed waiver from the state. The form is signed by the company president, Michael F. Stachowicz, with an effective date of 4/1/2025, indicating this is likely part of a new or renewed contract with the State of Ohio.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| 102-26_pricing__03_13_25_DSA.xls | XLS spreadsheet | |
| TJ_Specification-NEW.pdf | ||
| SDS-BJ_Super.pdf | ||
| Signature__4___1___002___44_.pdf | ||
| 102-26_Specs__03_13_25_.pdf | ||
| 102__26__recommend_Award_Letter.pdf | ||
| THORMA-JOINT_Data_Sheet_REV_1.20.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
AFFIRMATION AND DISCLOSURE FORM
By the signature affixed hereto, the Contractor affirms and understands that if awarded a contract, both the Contractor and any of its subcontractors shall perform no services requested under this Contract outside of the United States, not allow State data to be sent, taken, accessed, tested, maintained, backed-up, stored or made available remotely(located) outside of the United States unless a duly signed waiver from the State has been attained.
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.
EXPENDITURE OF PUBLIC FUNDS ON SERVICES PERFORMED BY RUSSIAN COMPANIES OR INSTITUTIONS.
The Contractor affirms to have read and understands Executive Order 2022-02D and shall abide by those requirements in the performance of this Contract. Pursuant to this Executive Order, all state agencies are prohibited from the purchase of services from Russian companies or institutions. This prohibition is in addition to and expands upon Executive Order 2019-12D which generally precludes the purchase of offshore services by the State of Ohio. Notwithstanding any other terms of this Contract, ODOT reserves the right to recover any funds paid for services the Contractor performs in Russia in violation of this Executive Order. ODOT does not waive any other rights and remedies provided to ODOT in this Contract.
The Contractor agrees to complete the attached Exhibit II, Contractor/Subcontractor Affirmation and Disclosure Form, to abide with Executive Order 2022-02D, which is incorporated and becomes a part of this Contract, affirming no services of the Contractor or its subcontractors under this Contract will be performed in Russia.
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 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)
373 Village Road Pennsdale, PA 17756
Not Applicable
Not Applicable
Ohio Ohio Statewide
Not Applicable
Not Applicable
373 Village Road Pennsdale, PA 17756
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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 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 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 State and is incorporated therein.
(AN ORIGINAL SIGNATURE IS REQUIRED)
Company Name: _____________________________
Signature: __________________________________
Print Name: ________________________________
Title: ______________________________________
Date: ______________________________________
Not Applicable
Not Applicable
Not Applicable
Dynamic Surface Applications, Ltd.
Michael F. Stachowicz
President
4/1/2025
| 2025-04-01T10:50:00-0400 | |
| Michael F. Stachowicz |
File details come from the government source that posted it. Updated .