Affirmation_and_Disclosure_Form__1_ (1).pdf

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Attached to
GT Uni Mac Industrial Washer installed
Solicitation number
SRC0000035573
Issued by
Butler County, Ohio

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This is an Affirmation and Disclosure Form related to a contract opportunity with the Ohio Department of Veterans Services for the purchase and installation of a Uni Mac UW Series High-Performance Hard Mount Washer Extractor at the Ohio Veterans Home Georgetown, located at 2003 Veterans Blvd, Georgetown, OH 45121. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore service performance, locating State data offshore, and purchasing from Russian institutions or companies. Contractors must disclose all locations where services will be performed, including principal business locations and subcontractor locations, as well as all locations where State data will be accessed, tested, maintained, backed-up, or stored. The form requires authorized contractor representatives to execute the affirmation and provide detailed information about service performance locations and data storage locations before, during, and after contract execution.

Contractors and their subcontractors have a duty to immediately disclose any changes or shifts in service locations to the State. The State reserves the right to terminate the contract if any services are performed or State data is located outside the United States unless the State provides a duly signed waiver. This form is incorporated as a binding part of any contract entered into with the State of Ohio and must be completed and signed by an authorized contractor representative with the contractor's name, title, and date provided.

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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:
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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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