Affirmation and Disclosure Form_4-17-24.pdf
PDF 84 KB Posted
- Attached to
- Cowan Lake State Park Tile installation on the walls and painting of cinder block in Shower House #2.
- Solicitation number
- SRC0000035932
- Issued by
- Clermont County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Natural Resources for the Cowan Lake State Park tile installation and painting project at Shower House #2. The form mandates that contractors disclose all locations where services will be performed, where subcontractors will perform work, and where state data will be stored. Contractors must affirm compliance with Executive Orders prohibiting offshore services, offshore data storage, and purchases from Russian institutions or companies. The project involves removing vinyl wall covering, patching walls, installing cement board and ceramic tiles with grout, painting exposed cinder block, and resetting fixtures including mirrors, sinks, toilets, soap dispensers, towel racks, benches, and handrails. Additionally, water supply lines must be detached and reattached, and under-sink pipes must be replaced. The work must be completed by May 30, 2026. Site visits are available by appointment between December 18, 2025, and January 19, 2026, by contacting Ronnie Nelson at (937) 416-6121 or Cole Holden at (937) 728-2564. Failure to conduct a site visit prior to bidding will not be accepted as grounds for contract release.
Contractors and their subcontractors are required to immediately notify the state of any changes or shifts in service locations before, during, or after contract execution. The state retains the right to immediately terminate the contract unless a duly signed waiver is obtained to perform services outside the United States. An authorized representative must sign the form, affirming that it is incorporated into any resulting contract with the state. No specific pricing information, funding sources, or award dates are provided in this disclosure 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 .