Affirmation and Disclosure Form_3-4-22.pdf
PDF 84 KB Posted
- Solicitation number
- SRC0000022034
- Issued by
- Wayne County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local contract opportunity for the replacement of deck boards on several fishing docks located in Williams and Defiance Counties, Ohio. The project requires the removal of all existing wood, rub rails, and cleats, with the reuse of rub rails and cleats and proper disposal of old lumber. The new decking shall be composite decking boards in a Pebble Gray or Winchester Gray color, secured to treated lumber frames attached to the underlying steel dock structure. The docks will remain in the water during the work, though the contractor may opt to remove them. A crane will be required for the project.
The contract opportunity requires the disclosure of the principal locations of the contractor's and any subcontractors' businesses, as well as the locations where the services and state data will be performed and stored. The contractor must also affirm their understanding of the state's policies regarding offshore services and data storage. Failure to provide this information may result in no award.
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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 .