Affirmation and Disclosure Form 4-17-24 Fill In.pdf
PDF 91 KB Posted
- Solicitation number
- SRC0000027092
- Issued by
- Ross County, Ohio
About this file
This is an Affirmation and Disclosure Form (Rev. 3/22) that requires contractors to disclose the locations where contract services will be performed and where state data will be stored. The form addresses Executive Orders prohibiting offshore services, offshore data storage, and purchasing from Russian institutions or companies. Contractors must provide detailed information about their principal business location, subcontractor locations, and where all services and data storage will occur.
The form requires contractors to immediately notify the state of any changes in service locations and acknowledges that the state has the right to terminate contracts if services are moved outside the United States without a state-approved waiver. The document must be signed by an authorized representative of the contractor, confirming their understanding that this form becomes part of any contract with the state. Failure to provide complete location information may result in no contract 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:
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