Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
PWC Jesse Owens State Park Pre Fab Shed with Porch
Solicitation number
SRC0000036766
Issued by
Montgomery County, Ohio

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This is an Affirmation and Disclosure Form required by the State of Ohio in connection with a pre-fabricated shed with attached porch procurement for Jesse Owens State Park under the Ohio Department of Natural Resources. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions. Contractors must disclose all locations where services will be performed and where State data will be accessed, maintained, backed up, or stored, including information for any subcontractors utilized. The specific project involves delivery and installation of a 25' x 24' minimum pre-fabricated shed with covered porch to Jesse Owens State Park in McConnelsville, Ohio. The structure must include a 36" exterior door with window and lock, a minimum of five 30"x36" windows, brown metal roofing to match existing structures, treated flooring, and a color scheme selected by the Park Manager to match existing facilities. Delivery costs must be included in the bid price, and the shed will be placed on a #57 limestone foundation provided by the State.

The form requires contractors to certify that all services and State data remain within the United States, with the State retaining the right to terminate the contract if services are performed or data is located outside the United States without a signed State waiver. Contractors must notify the State immediately of any changes or shifts in service location before, during, or after contract execution. Bidders must submit examples or photos of two prior similar projects. The delivery address is Jesse Owens State Park, 100 Natural Resources Road 1, McConnelsville, Ohio 43756, with contact information provided for Park Manager Ron Mingus (740-249-5048) and Assistant Manager Sara Gudorf (740-487-5377). All equipment used on-site must be free of sediment and debris to minimize invasive species introduction, and any timber matting must be new.

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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: __________________________________

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