Affirmation and Disclosure Form_4-17-24 Fill In & Signature Required.pdf
PDF 92 KB Posted
- Solicitation number
- SRC0000032684
- Issued by
- Ashland County, Ohio
About this file
The document is an Affirmation and Disclosure Form related to a state contract opportunity, requiring contractors to provide detailed information about their business locations and service performance sites. The form mandates that contractors affirm their understanding of Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions. Contractors must disclose the principal business location, locations where services will be performed, and where state data will be located, including details for both the primary contractor and any subcontractors.
The form emphasizes a critical compliance requirement that contractors and subcontractors are obligated to immediately disclose any changes in service locations to the state 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 signed waiver. The document requires an authorized contractor representative to sign, acknowledging their understanding that this form is incorporated into any potential state contract and that they are legally bound to the disclosed location and service information.
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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:
| Name: |
| Address City State Zip: |
| Name_2: |
| Address City State Zip_2: |
| Name_3: |
| Address City State Zip_3: |
| Name_4: |
| Address City State Zip_4: |
| 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: |
| Title: |
| Date: |
| Required Address Performance of Service: |
| Required Address Business Location: |
| Required Business Location City State Zip: |
| Requried Performance of Service City State Zip_2: |
| Required Address State Data Location: |
| Required State Data City State Zip_3: |
| Print Name for Required Signature Clarification: |
File details come from the government source that posted it. Updated .