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

92 KB Posted

Attached to
PWC Dredge L (The Millie) Dredge Pump Impeller
Solicitation number
SRC0000034287
Issued by
Fairfield County, Ohio

About this file

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form related to state contract requirements, specifically addressing offshore service restrictions and location disclosures for contractors. The form requires contractors to provide detailed information about their principal business location, service performance locations, and the locations of any state data storage, including information for both the primary contractor and any potential subcontractors. Contractors must affirm their understanding of Executive Orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions or companies.

The form mandates ongoing transparency, with contractors required to disclose any changes in service or data location to the state before, during, and after contract execution. The state retains the right to immediately terminate the contract if services are moved outside the United States without a formal waiver. By signing the form, the contractor acknowledges that this document is incorporated into any potential state contract and that they are authorized to execute the disclosure, affirming compliance with the specified location and service restrictions.

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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 .