Affirmation and Disclosure Form 4-17-24 Fill In.pdf
PDF 91 KB Posted
- Attached to
- PWC SW L Cowan Lake Campstore Flooring & Front Deck Replacement State and local contract opportunity
- Solicitation number
- SRC0000026148
- Issued by
- Clermont County, Ohio
About this file
This document is an Affirmation and Disclosure Form required for a state and local government contract. The form requires the contractor to disclose the location of the principal business, the location where services will be performed, and the location where any state data will be stored, including any subcontractors involved. The contractor must affirm their understanding of the prohibition on performing offshore services or storing state data offshore, and agree to notify the state of any changes in service locations before, during, and after the contract. The contractor must provide this information to be considered for the contract award.
The form does not provide details on the specific contract opportunity, such as the products or services requested, project overview, response due dates, award information, or contract term. It focuses solely on the contractor's disclosure requirements regarding the location of services and data storage. No pricing terms, set-asides, incumbent information, funding sources, or other salient contract details are included in this 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:
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