Affirmation and Disclosure BLANK.pdfAffirmation and Disclosure BLANK.pdf
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- Solicitation number
- SRC0000041982
- Issued by
- Fairfield County, Ohio
About this file
This is an Affirmation and Disclosure Form used by the State of Ohio, Department of Rehabilitation and Correction (ODRC), in connection with a structural fire escape inspection contract opportunity at Southeastern Correctional Institution (SCI) located in Lancaster, Ohio. The form requires contractors to disclose and affirm compliance with applicable Executive Orders prohibiting the performance of offshore services, locating state data offshore, or purchasing from Russian institutions or companies. Contractors must provide their principal business location, all locations where services will be performed, and all locations where state data will be stored, including information for any subcontractors. The contract scope involves professional structural engineering services to inspect and certify six exterior emergency egress structures in compliance with Ohio Fire Code Section 1104.16.5.1, requiring verification that all stairways, balconies, ladders, cantilevers, and structural anchorages safely support a minimum uniform live load of 100 pounds per square foot.
The Affirmation and Disclosure Form is a mandatory component of any contract executed with the State of Ohio and must be completed and signed by an authorized representative of the contractor. Contractors and their subcontractors are under a duty to disclose any changes or shifts in the location of services performed before, during, and after contract execution and must notify the State immediately of any such changes. The State reserves the right to immediately terminate the contract unless a duly signed waiver has been obtained to perform services outside the United States. The form serves as a compliance mechanism to ensure all work meets state regulatory requirements and that sensitive state data remains protected within approved geographic locations.
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Text version
AFFIRMATION AND DISCLOSURE FORM
Rev. 3/22 Page 1 of 2
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.
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)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
Contractor 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 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.
By:
Contractor
Print Name:
Title:
Date:
File details come from the government source that posted it. Updated .