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

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form for a state contract, requiring contractors to disclose specific details about their business and service locations. The form mandates that contractors affirm their understanding of Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions or companies. Contractors must provide comprehensive information about their principal business location, service performance locations, and the locations where state data will be stored, including details for both the primary contractor and any subcontractors.

The form emphasizes ongoing transparency, requiring contractors to immediately disclose any changes in service or data location before, during, and after contract execution. The State retains the right to terminate the contract if services are performed outside the United States without a proper waiver. By signing the form, the contractor acknowledges that this disclosure is an integral part of the potential contract and that they are authorized to provide this information. The form includes spaces for the contractor's signature, printed name, title, and date of submission, ensuring a formal and legally binding commitment to the disclosed information.

View the file

Other files for this state and local contract opportunity

Other files attached to PWC SW L Cowan Lake Campstore Flooring & Front Deck Replacement, newest first.
File Type Posted
REVISED RFQ_Cowan_Lake_Campstore_Flooring_and_Front_Deck_Replacement_Scope_of_Work.pdf PDF
S-LG.2 Ohio Buys Viewing and Responding to Solicitations LG v2.0.pdf PDF
Standard_T_C 3-1-24.pdf PDF
OB Addendum to Bid Quote 09 24 2024.pdf PDF
Ohio Buys New Bidder.pdf PDF
Affirmation and Disclosure Form 4-17-24 Fill In.pdf PDF
RFQ Cowan Lake Campstore Flooring and Front Deck Replacement Scope of Work.pdf PDF
S-LG.2 Ohio Buys Viewing and Responding to Solicitations LG v2.0.pdf PDF
OB Addendum to Bid Quote 09 24 2024.pdf PDF
Standard_T_C 3-1-24.pdf PDF
Ohio Buys New Bidder.pdf PDF
Standard_T_C 3-1-24.pdf PDF
Affirmation and Disclosure Form 4-17-24 Fill In.pdf PDF
OB Addendum to Bid Quote 09 24 2024.pdf PDF
RFQ Cowan Lake Campstore Flooring and Front Deck Replacement Scope of Work.pdf PDF
Ohio Buys New Bidder.pdf PDF
S-LG.2 Ohio Buys Viewing and Responding to Solicitations LG v2.0.pdf PDF
Show all 17

On GovTribe

Work with this file on GovTribe

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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:

File details come from the government source that posted it. Updated .