Affirmation and Disclosure Form_3-4-22.pdf
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- Attached to
- Middle Bass Island Shelter House Chimney Repair
- Solicitation number
- SRC0000018986
- Issued by
- Ottawa County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local contract opportunity for the Middle Bass Island Shelter House Chimney Repair project in Ottawa County, Ohio. The scope of work involves grinding out existing cracks in the mortar joints, tuck pointing, sealing the crown with a crown coat, installing an outside mount chimney cap, waterproofing the entire exterior of the chimney, and other related repairs. The project has a deadline of June 14, 2024, and offerors are encouraged to conduct a site visit prior to submitting a bid. The contract will be awarded to the lowest responsive and responsible bidder based on the low lot total bid. The successful bidder will be required to sign an Addendum to Bid Quote or Personal Services Agreement. Invoices must be submitted directly to Ohio Shared Services, and the purchase order is only valid through June 30 of the applicable year.
The document also includes instructions for submitting invoices, which must include the purchase order number, supplier name, ship-to/service facility information, invoice number, date of service, itemized charges, and no state sales tax. There are no specific set-asides or incumbent information provided, and the funding source is not explicitly stated.
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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 .