Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Attached to
- LaSuAn Copperbelly Tree Planting 2025
- Solicitation number
- SRC0000026550
- Issued by
- Wayne County, Ohio
About this file
This is an Affirmation and Disclosure Form (Rev. 3/22) that contractors must complete when entering into contracts with the State. The form requires contractors to affirm their understanding of Executive Orders prohibiting offshore services, offshore data storage, and purchasing from Russian institutions or companies. Contractors must disclose the principal location of their business, locations where services will be performed, and locations where state data will be stored - both for themselves and any subcontractors they plan to use.
The form mandates immediate disclosure of any changes in service locations before, during, or after contract execution. Contractors must obtain a signed state waiver to perform services outside the United States, or risk immediate contract termination. The document must be signed by an authorized representative of the contractor, acknowledging that this form becomes an incorporated part of any contract with the State. The form consists of three main sections for location disclosures and includes space for up to five subcontractor listings per section.
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| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| OPERS Independent Contractor Form_fillable PDF Form.pdf | ||
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| Copperbelly Tree planting 24.docx | DOCX document | |
| Standard Terms and Conditions.pdf |
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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 .