Affirmation and Disclosure Form_3-4-22 (4).pdf
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- Attached to
- Aquilla Lake Boat Ramp parking area sealing
- Solicitation number
- SRC0000022593
- Issued by
- Geauga County, Ohio
About this file
The document is an Affirmation and Disclosure Form related to a state and local contract opportunity for sealing the asphalt parking area and adding thermoplastic striping at the Bonner Road Boat Ramp parking area at Berlin Lake in the state of Ohio. The form requires the contractor to disclose the principal location of their business, the location where the services will be performed, and the location where any state data will be stored. The contractor must also affirm that they understand and will comply with restrictions on offshore services and purchasing from Russian institutions. The related state and local contract opportunity provides a brief description of the requested work, which includes sealing the asphalt parking area and adding thermoplastic striping.
The document does not provide details on pricing terms, set asides, incumbents, funding requirements or sources, or other salient commercial information. It is focused on the location and performance disclosure requirements for the contractor.
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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 .