Affirmation and Disclosure Form 4-17-24 Fill In.pdf

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Attached to
PWC SW E John Bryan Toro Mower
Solicitation number
SRC0000028518
Issued by
Greene County, Ohio

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This document is an Affirmation and Disclosure Form related to a state government contract, requiring contractors to provide detailed information about their business locations and service performance sites. The form mandates disclosure of the principal business location, specific locations where services will be performed, and the precise locations where state data will be stored, both for the primary contractor and any subcontractors involved in the project.

The form emphasizes strict requirements regarding offshore services and data storage, with contractors obligated to immediately disclose any changes in service or data location to the state. Contractors must affirm their understanding that the state retains the right to terminate the contract if services are performed outside the United States without obtaining a formal waiver. The document serves as a critical compliance mechanism for ensuring transparency in service delivery, data management, and geographic constraints for state contracts, with particular emphasis on preventing service performance or data storage in restricted jurisdictions.

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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:
Address_2:
City State Zip_2:
Name_3:
Address City State Zip_3:
Name_4:
Address City State Zip_4:
Address_3:
City State Zip_3:
Name_5:
Name_6:
Name_7:
Name_8:
Name_9:
Address City State Zip_5:
Address City State Zip_6:
Address City State Zip_7:
Address City State Zip_8:
Address City State Zip_9:
Contractor:
Print Name:
Title:
Date:

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