Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
DNR facilities Plumbing Contract awarded by County
Solicitation number
SRC0000034884
Issued by
Ashland County, Ohio

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This is an Affirmation and Disclosure Form (Version 5/24) required by a state for contractors entering into agreements with the state government. The form serves as a certification document through which contractors affirm their understanding of and compliance with applicable Executive Orders prohibiting the performance of offshore services, the location of state data offshore, and the purchase of goods or services from Russian institutions or companies. The form requires contractors to provide comprehensive disclosure of all service performance locations and state data storage locations for both the primary contractor and any subcontractors involved in contract execution.

The form mandates disclosure in three primary areas: the contractor's principal business location and subcontractor locations; all locations where services will be performed by the contractor and subcontractors; and all locations where state data will be accessed, tested, maintained, backed up, or stored. Contractors and subcontractors are placed under a continuing duty to disclose any changes or shifts in service location before, during, and after contract execution, with immediate notification required to the state. The state reserves the right to terminate any contract if services are performed or state data is located outside the United States unless the state provides a duly signed waiver. The form requires authorization by a contractor representative with proper signatory authority and must be incorporated into and executed as 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:

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