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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This is an Affirmation and Disclosure Form required by the Ohio Department of Transportation for the Request for Quote 2111 soliciting Viavi CX200 communications testing equipment. Bidders must complete and submit this form certifying compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions. The form requires contractors to identify 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. If subcontractors are utilized, their names and service locations must be disclosed in the same manner. The deadline for quote submission is April 17, 2026. This is a second round procurement open to both previously invited suppliers and the general public following an initial round that failed to correctly invite all potential suppliers.

Contractors and subcontractors must affirm that all services will be performed and all state data will be located exclusively within the United States, with a duty to immediately disclose any changes or shifts in service locations before, during, and after contract execution. The state reserves the right to terminate the contract if services are performed or state data is located outside the United States without a signed waiver. Contractors must submit unit pricing for all specified equipment items and comply with Ohio's standard procurement requirements, including execution of a Data Privacy and Security Addendum, maintenance of commercial general liability insurance of at least $1,000,000 per occurrence, and adherence to federal and state nondiscrimination laws and drug-free workplace standards. The contract will be awarded to the lowest responsive and responsible bidder, with payment due thirty calendar days after invoice receipt and deliverables provided F.O.B. Destination at contractor expense.

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Affirmation_and_Disclosure_Form_5-20-24_fillable_form.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: __________________________________

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