Affirmation_and_Disclosure_Form__1_ (2).pdfAffirmation_and_Disclosure_Form__1_ (2).pdf

PDF 104 KB Posted Apr 2, 2026

Attached to: Dietician Services
Solicitation number: SRC0000037849
Issued by: Butler County, Ohio

About this file

Written by GovTribe AI · Sep 19, 2026

This is an Affirmation and Disclosure Form required by the state of Ohio for contractors entering into contracts with state agencies. The form applies to the Ohio Department of Veterans Services' solicitation for Dietician Services at a 168-bed nursing home located at 2003 Veterans Boulevard, Georgetown, Ohio 45121. The dietician will provide approximately 8 hours of services per week. The form requires contractors to affirm compliance with Executive Orders prohibiting the performance of offshore services, locating state data offshore, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location of the contractor and all subcontractors, the locations where services will be performed, and the locations where any state data will be accessed, tested, maintained, backed up, or stored.

Contractors and their subcontractors are under a duty to disclose any changes or shifts in service locations before, during, and after contract execution and must notify the state immediately of such changes. The state reserves the right to terminate the contract if any services are performed or state data is located outside the United States unless a duly signed waiver is obtained from the state. The form must be executed by an authorized representative of the contractor, who must certify that they are duly authorized to sign the document and acknowledge that the form is incorporated into any resulting contract with the state. This solicitation is designated for Minority Business Enterprise (MBE) suppliers certified under specific UNSPSC codes, and only qualified, licensed dietitians are acceptable bidders.

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File	Type	Posted
Business_Associate_Agreement (2).pdfBusiness_Associate_Agreement (2).pdf	PDF	Apr 2, 2026

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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:

Name_6:

Name_7:

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:

File details come from the government source that posted it. Updated Sep 19, 2026.