Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
ITRFQ0003514 Survey Software Solution 2. 0 State and local contract opportunity
Solicitation number
SRC0000035073
Issued by
Ohio

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This is an Affirmation and Disclosure Form (Version 5/24) required for state contractors. The form establishes compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions or companies. Contractors must disclose their principal business location, all locations where services will be performed, and all locations where state data will be accessed, tested, maintained, backed-up, or stored. The form requires disclosure of subcontractor information including their names and business locations, as well as the locations where subcontractors will perform services and maintain state data. Contractors must identify all service performance locations and state data locations in the spaces provided on the form or by attachment. If no subcontractors are being used, contractors must indicate "Not Applicable" in the appropriate sections.

Contractors and their subcontractors are subject to a duty of disclosure regarding any changes or shifts in service location before, during, and after contract execution. Contractors must notify the state immediately of any such changes. The form explicitly prohibits performance of services or location of state data outside the United States unless a duly signed waiver from the state has been obtained. The state reserves the right to terminate the contract if services are performed or data is located outside the United States without proper authorization. An authorized contractor representative must sign and date the form, certifying that they are duly authorized to execute the affirmation and acknowledging that the form is incorporated into and becomes part of any contract entered into 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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