Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Attached to
- Killdeer Pond #33 Boat Ramp Repair
- Solicitation number
- SRC0000034240
- Issued by
- Wayne County, Ohio
About this file
The document is an Affirmation and Disclosure Form (Revision 3/22) designed to ensure compliance with Executive Orders regarding offshore services, data location, and purchasing restrictions. The form requires contractors to disclose the principal business location, service performance locations, and the specific locations where state data will be stored, both for the primary contractor and any potential subcontractors. Contractors must provide detailed address information for each category and affirm that they understand their obligation to immediately notify the state of any changes in service or data location.
The form emphasizes strict guidelines about performing services within the United States, with the state retaining the right to immediately terminate the contract if services are moved offshore without a formal waiver. Contractors must explicitly affirm they have read and understood the applicable Executive Orders prohibiting offshore services, locating state data outside the U.S., or purchasing from Russian institutions or companies. The document requires an authorized representative of the contractor to sign, print their name, provide their title, and date the form, acknowledging that this disclosure is a mandatory component of any potential contract with the state.
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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 .