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

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Attached to
PWC SW M Caesar Creek Gray Water Boxes
Solicitation number
SRC0000025713
Issued by
Warren County, Ohio

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This document is an Affirmation and Disclosure Form for a state and local government contract opportunity. The form requires the contractor to disclose the location(s) where the contract services will be performed and where any state data will be located, including any subcontractor locations. The contractor must affirm their understanding of applicable executive orders regarding the prohibition of offshore services and purchasing from Russian institutions. The contractor agrees to notify the state of any change in the location of services during the contract term, and the state reserves the right to terminate the contract if services are performed outside the United States without a waiver.

The form requires the contractor to provide the principal location of their business, as well as the names and locations of any subcontractors. It also requests information on the specific locations where the contract services will be performed and where any state data will be stored, for both the contractor and any subcontractors. The contractor must acknowledge that they are duly authorized to execute the form, which is incorporated into the contract.

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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:

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