Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Solicitation number
- SRC0000035709
- Issued by
- Preble County, Ohio
About this file
This is an Affirmation and Disclosure Form for the State of Ohio related to a janitorial services contract for the Put-in-Bay Aquatic Visitor Center located on South Bass Island. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchasing from Russian institutions or companies. Contractors must disclose the principal location of their business, all locations where services will be performed, and all locations where state data will be located, including information for any subcontractors used. The form mandates that contractors provide complete location information in the designated spaces or by attachment, with failure to provide this information potentially resulting in no award of the contract.
The form establishes an ongoing disclosure obligation requiring contractors and subcontractors to notify the State immediately of any changes or shifts in service location before, during, and after contract execution. The State reserves the right to immediately terminate the contract if services are performed outside the United States unless the contractor obtains a duly signed waiver from the State. The executing contractor representative must be duly authorized to sign the form and acknowledge that it constitutes a binding part of any resulting contract with the State of Ohio.
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Other files
| File | Type | Posted |
|---|---|---|
| OPERS Independent Contractor Form_fillable PDF Form.pdf | ||
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| PIBAVC Janitorial Services Scope of Work 12-2025.docx | DOCX document | |
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys.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 .