Affirmation and Disclosure Form_4-17-24.pdf
PDF 84 KB Posted
- Solicitation number
- SRC0000036914
- Issued by
- Meigs County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Natural Resources for the Grand Lake St. Mary's State Park Fence Installation with 2 Gates project. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions or companies. Contractors must disclose the principal business location, all locations where services will be performed, and all locations where state data will be stored, including information for any subcontractors used on the project. The form requires detailed address information for the contractor and each subcontractor across three categories: principal business location, service performance locations, and state data storage locations.
Contractors and subcontractors are under a duty to immediately disclose any changes or shifts in service performance locations before, during, and after contract execution. The State reserves the right to immediately terminate the contract if services are performed outside the United States without a duly signed waiver from the State. The contractor must sign the form acknowledging authorization to execute it and understanding that the form is incorporated into and becomes part of any resulting contract with the State.
View the file
Other files
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
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 .