Affirmation_and_Disclosure_Form_5-20-24_fillable_form (1).pdfAffirmation_and_Disclosure_Form_5-20-24_fillable_form (1).pdf

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Attached to
Ohio Department of Health DOH61906 : Bureau of Public Health Laboratory SFY27 -MiSeq i100 Plus System or equivalent and MiSeq i100 Plus Silver Support Plan or equivalent RFP
Solicitation number
SRC0000041150
Issued by
Franklin County, Ohio

About this file

Written by GovTribe AI ·

This is an Affirmation and Disclosure Form (Version 5/24) required by the Ohio Department of Health for the MiSeq i100 Plus System procurement. The form mandates that contractors affirm their compliance with Executive Orders prohibiting the performance of offshore services, locating State data offshore, or purchasing from Russian institutions or companies. Contractors must disclose the principal business location of the contractor and all subcontractors, identify all locations where services will be performed, and specify all locations where State data will be accessed, tested, maintained, backed-up, or stored. The form requires detailed information about both the contractor and any subcontractors involved in contract performance, with multiple fields provided to accommodate multiple service locations and data storage locations.

Contractors executing this form acknowledge a continuing duty to disclose any changes or shifts in service locations or data storage locations before, during, and after contract execution, with immediate notification required to the State. The State retains the right to terminate the contract if any services are performed or State data is located outside the United States unless the State provides a duly signed waiver. The form must be executed by an authorized representative of the contractor who certifies they have read and understood the affirmation and disclosure requirements and that the form constitutes an incorporated part of any resulting contract with the State.

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Version 5/24 Page 1 of 2

AFFIRMATION AND DISCLOSURE FORM

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.

The Contractor shall provide the name(s) and location(s) where all services under this Contract will be performed and where State data will be located in the spaces provided below or by attachment. If the Contractor will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.

Contractor Name: ___________________________ Contract Number:

1. Principal business location of Contractor:

(Address) (City, State, Zip)

Name(s)/Principal business location(s) of subcontractor(s):

(Name) (Address, City, State, Zip)

2. Location(s) where services will be performed by Contractor:

Name(s)/Location(s) where services will be performed by subcontractor(s):

Version 5/24 Page 2 of 2

3. Location(s) where any State data associated with any of the services Contractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:

Name(s)/Location(s) where any State data associated with any of the services any subcontractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:

Contractor also 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 to notify the State immediately of any such change or shift in location of its services. The State has the right to terminate the contract if any services are performed or State data is located outside of the United States unless a duly signed waiver from the State has been attained.

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: __________________________________ Authorized Contractor Signature

Print Name: ___________________________

Title: __________________________________

Date: __________________________________

Contractor Name:
Contract Number:
Address:
City State Zip:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Address_3:
City State Zip_3:
Name_3:
Name_4:
Address City State Zip_3:
Address City State Zip_4:
Address_4:
City State Zip_4:
Address_5:
City State Zip_5:
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:
Print Name:
Title:
Date:

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