Affirmation_and_Disclosure_Form__1_.pdf

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Attached to
Wander/Elopement guard system
Solicitation number
SRC0000034914
Issued by
Butler County, Erie County, Ohio

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This is an Affirmation and Disclosure Form (Version 5/24) that contractors must complete as a requirement for state contracts. The form serves as a compliance document ensuring that contractors acknowledge and affirm their understanding of applicable Executive Orders regarding prohibitions on offshore service performance, locating state data offshore, and purchasing from Russian institutions or companies. Contractors are required to disclose the principal business location of the contractor and all subcontractors, identify all locations where services will be performed by both the contractor and any subcontractors, and specify all locations where state data will be accessed, tested, maintained, backed up, or stored. The form provides multiple line items for contractor and subcontractor information to accommodate various operational arrangements.

The form establishes mandatory disclosure obligations requiring contractors and subcontractors to notify the state of any changes or shifts in service location before, during, and after contract execution. Contractors must certify that all services and state data will remain within the United States unless the state provides a duly signed waiver. The state retains the right to terminate any contract if services are performed or state data is located outside the United States without prior waiver authorization. An authorized contractor representative must execute the form, certifying that they are duly authorized to do so and that they have read and understood that this affirmation is incorporated as part of any resulting contract with the state.

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Other files

File Type Posted
01_Model_Contract_2025__2_.doc DOC document
State_of_Ohio_Terms_and_Conditions__5___1_.pdf PDF
Wander-Elopement Guard System Scope of Work SRC0000034914.pdf PDF
Certification_Statement__2___1_ (2).pdf PDF

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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:

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