Affirmation and Disclosure Form_4-17-24 Fill In & Signature Required.pdf

PDF 92 KB Posted

Attached to
PWC SW L Paint Creek Marina Pumpout Lift Station Electrical Box Repairs
Solicitation number
SRC0000032604
Issued by
Sandusky County, Ohio

About this file

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form designed for contractors seeking to enter into a state contract. The form requires contractors to disclose the principal location of their business, the locations where services will be performed, and the locations where state data will be stored, including details about any subcontractors. Contractors must affirm that they have read and understand executive orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions or companies.

The form mandates that contractors immediately notify the state of any changes in service locations before, during, or after contract execution, with the state retaining the right to terminate the contract unless a signed waiver is obtained to perform services outside the United States. By signing the form, the contractor acknowledges that this document is part of any potential contract and that they are authorized to execute it. The form requires the contractor to provide their signature, printed name, title, and the date of execution, ensuring transparency and compliance with state regulations regarding service performance and data management.

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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:

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 .