Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
PWC Pymatuning Aluminum Courtesy Docks
Solicitation number
SRC0000035766
Issued by
Ashland County, Ohio

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This is an Affirmation and Disclosure Form (Version 5/24) required by the State of Ohio for contractors bidding on the PWC Pymatuning Aluminum Courtesy Docks project at Pymatuning State Park. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore services performance, offshore State data location, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location, all subcontractor names and locations, service performance locations, and locations where State data will be accessed, tested, maintained, backed-up, or stored. The specific project involves procurement of two aluminum gangways (3' W x 20' L and 4' W x 20' L) and two courtesy docks with WearDeck decking to be factory assembled and delivered to the Padanaram Boat Launch in Andover, Ohio. The docks must include specified hardware, galvanized steel truss frames, polyethylene floats, and marine-grade structural decking, with delivery required by March 13, 2026.

Contractors and subcontractors are under a continuing duty to disclose any changes or shifts in service locations before, during, and after contract execution, with immediate notification required to the State. The State reserves the right to terminate the contract if any services are performed or State data is located outside the United States without a duly signed waiver. The form requires authorization by a duly authorized contractor representative with signature, printed name, title, and date. All applicable warranties must be expressly stated in the bidder's response.

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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:
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