Affirmation and Disclosure Form 4-17-24 Fill In.pdf
PDF 91 KB Posted
- Solicitation number
- SRC0000023373
- Issued by
- Vinton County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state and local government contract opportunity. The form requires the contractor to disclose the principal location of their business, the locations where services will be performed, and the locations where any state data will be stored, including for any subcontractors. The contractor must affirm their understanding that they have a duty to disclose any changes in the location of services or data storage before, during, and after the contract execution. The state maintains the right to terminate the contract if services are performed outside the United States without prior written approval.
The form requires the contractor to provide detailed address information for their principal place of business, as well as any subcontractor locations where services will be performed or state data will be stored. The contractor must acknowledge that they are duly authorized to execute the form and that it will be incorporated into any contract they enter into with the state.
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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:
| Address: |
| City State Zip: |
| Name: |
| Address City State Zip: |
| Name_2: |
| Address City State Zip_2: |
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| Name_3: |
| Address City State Zip_3: |
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| Name_5: |
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| Address City State Zip_5: |
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| Contractor: |
| Print Name: |
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| Date: |
File details come from the government source that posted it. Updated .