Affirmation and Disclosure Form 4-17-24 Fill In.pdf
PDF 91 KB Posted
- Solicitation number
- SRC0000027076
- Issued by
- Stark County, Ohio
About this file
This is an Affirmation and Disclosure Form (Rev. 3/22) that contractors must complete regarding prohibitions on offshore services, data storage, and purchasing from Russian institutions or companies. The form requires contractors to provide detailed information about the locations where services will be performed and where state data will be stored, both for the primary contractor and any subcontractors.
The form requires contractors to disclose three key location categories: principal business location, service performance locations, and state data storage locations. Contractors must immediately notify the state of any changes in service locations, with the state retaining the right to terminate the contract if services are moved outside the United States without a signed waiver. The form must be signed by an authorized representative of the contractor, acknowledging that it becomes part of any contract with the state. No specific pricing terms, set-asides, or funding requirements are mentioned 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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