Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Attached to
- Cooper Hollow Wetland Dredging
- Solicitation number
- SRC0000019522
- Issued by
- Jackson County, Ohio
About this file
This document is an Affirmation and Disclosure Form for a state and local contract opportunity in Ohio. The contract involves the removal of vegetation and soil to a median depth of 18-24 inches over an approximately 11,155 square yard area for the Cooper Hollow Wetland Dredging project in Jackson County. All woody vegetation must be removed and placed along the boundary of the wetland, and all disturbed soil must be excavated and removed from the site. The excavated fill shall be hauled to a separate location and dumped on the Cooper Hollow Wildlife Area off Rempel Road.
The document requires the contractor to disclose the principal location of their business, the location where services will be performed, and the location where state data will be stored, including any subcontractor information. The contractor affirms that they have read and understand the applicable Executive Orders regarding the prohibitions of offshore services, locating state data offshore, or purchasing from Russian institutions or companies. The state has the right to terminate the contract if the contractor fails to disclose any changes or shifts in the location of services performed.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| Cooper Hollow Wetland A.pdf | ||
| Standard Terms and Conditions (10).pdf | ||
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys (1).docx | DOCX document | |
| CH Wetland 1.pdf | ||
| OPERS Independent Contractor Form_fillable PDF Form (10).pdf | ||
| Fill Dump Location.pdf | ||
| Cooper Hollow Wetland scope of work.docx | DOCX document |
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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 .