Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Attached to
- Darke Wildlife Area Firebreak Bush Hogging FY25
- Solicitation number
- SRC0000021930
- Issued by
- Darke County, Ohio
About this file
This document is an Affirmation and Disclosure Form for a state and local contract opportunity. The form requires the contractor to affirm their understanding of the prohibitions on performing offshore services or locating state data offshore, and to disclose the locations where services will be performed and where state data will be located, for themselves and any subcontractors. The contractor must also agree to notify the state of any changes in the location of services during the contract. The related state and local contract opportunity is for Darke Wildlife Area Firebreak Bush Hogging in the state of Ohio for fiscal year 2025.
The form does not provide details on pricing, set asides, incumbents, funding sources, or other salient information about the contract opportunity. It focuses solely on the affirmation and disclosure requirements related to the location of services and data.
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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 .