Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
D22 - Viavi CX200 (RFQ 2111)
Solicitation number
SRC0000038172
Issued by
Ohio

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Written by GovTribe AI ·

This is an Affirmation and Disclosure Form (Version 5/24) required by the State of Ohio for contractors bidding on state contracts, specifically for the D22 - Viavi CX200 RFQ 2111. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore services performance, offshore state data location, and purchasing from Russian institutions or companies. Contractors must disclose all principal business locations, locations where services will be performed, and locations where state data will be accessed, tested, maintained, backed up, or stored. The form applies to both the prime contractor and any subcontractors involved in the contract. Contractors are required to provide complete information for up to nine subcontractors, with separate sections for their respective service locations and data handling locations.

The form imposes an ongoing disclosure obligation, requiring contractors to notify the State immediately of any changes or shifts in service locations before, during, or after contract execution. The State reserves the right to terminate the contract if any services are performed or state data is located outside the United States unless the contractor obtains a duly signed waiver from the State. The authorized contractor representative must sign and date the form, affirming that they are duly authorized to execute it and that the form becomes incorporated into any resulting contract with the State. This disclosure requirement applies to the procurement of Viavi CX200 equipment and related accessories for Ohio.

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Purchasing Standard Terms and Conditions - 05-2025.pdf PDF
Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf PDF
Purchasing Standard Terms and Conditions - 05-2025.pdf PDF

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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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