Affirmation and Disclosure Form_3-4-22 (1).pdf
PDF 84 KB Posted
- Attached to
- Jackson Fish Unit Building Renovation
- Solicitation number
- SRC0000019687
- Issued by
- Knox County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local contract opportunity in Ohio. The form requires the contractor to provide information about the location(s) where services will be performed and where state data will be located, including any subcontractor information. The contractor must also affirm that they have read and understand applicable executive orders regarding the prohibition of offshore services and the purchase of goods and services from Russian institutions or companies. The related state and local contract opportunity is for the Jackson Fish Unit Building Renovation project, which includes replacing the roof, gutters, an interior man door, an interior wall, and an awning over the main entrance. Additionally, the project will replace the exterior main entrance door with a steel security door and frame the window spaces with plywood, insulation, and vinyl siding.
The document does not provide any details on pricing terms, set asides, incumbents, funding requirements or sources, or other financial information. It focuses solely on the location and offshore service requirements for the contractor and any subcontractors.
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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 .