Affirmation_and_Disclosure_-_Fairborn_Equipment_Midwest_2.13.24.pdf
PDF 184 KB Posted
- Attached to
- Competitive Selection OH|DOT226A24-1
- Contract number
- DOT226A24-1
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state contract, specifically involving the Ohio Department of Transportation (ODOT) and a contractor located at 5155 Financial Way, Suite 13 in Mason, OH 45040. The form addresses compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing services from Russian companies or institutions, expanding upon a previous executive order that generally precludes offshore services.
The form indicates that the contractor affirms no services will be performed outside the United States, and no state data will be sent, accessed, or stored remotely outside the country without a signed waiver from the state. No specific goods or services are detailed in this document, which appears to be a standard compliance form ensuring the contractor's commitment to performing work domestically and avoiding engagement with Russian entities. The document is signed by Ryan Halbert, Territory Sales Manager, on 2.13.24, and serves as a mandatory disclosure and affirmation prior to contract execution.
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Other files
| File | Type | Posted |
|---|---|---|
| 226A-24_Bid_Document.pdf | ||
| Signature.pdf | ||
| 226A-24_Pricing_2024-01-31_-_Fairborn_Equipment_Midwest.xlsx | XLSX spreadsheet |
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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:
_5155 Financial Way, Suite 13_________ Mason, OH 45040________________
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
__________________ Not Applicable ________ _________________________________
(Name) (Address, City, State, Zip)
_________________ Not Applicable__________ _________________________________
2. Location where services will be performed by Contractor:
_____________ Not Applicable ___________ _________________________________
Name/Location where services will be performed by subcontractor(s):
__________________ Not Applicable _______ _________________________________
_____________________ Not Applicable ____ _________________________________
3. Location where state data will be located, by Contractor:
__________ Not Applicable ___________ _________________________________
Name/Location(s) where state data will be located by subcontractor(s):
_________________ Not Applicable ___ _________________________________
__________ Not Applicable ______________ _________________________________
___________ Not Applicable ______________ _________________________________
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.
Signature: ___________________________________
Contractor
Print Name: _______________________________
Title: ___________________________________
Date: ___________________________________
Ryan Halbert Territory Sales Manager 2.13.24
File details come from the government source that posted it. Updated .