Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
D11 ODOT - Testing Equipment Automatic Grinder and Grinding Wheels
Solicitation number
SRC0000037505
Issued by
Tuscarawas County, Ohio

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This is an Affirmation and Disclosure Form required by the Ohio Department of Transportation for a contract to purchase testing equipment including one UTC-1060-N Automatic Grinding Machine with Cabinet for grinding concrete, rock, and natural stone, two UTC-1042 Grinding Wheels for the machine, and shipping of the equipment to 2201 Reiser Ave SE in New Philadelphia, Ohio 44663. The equipment must feature selectable advance grinding time functionality with an optimum grinding time of 90 to 120 seconds per end of specimen. Bidders are required to quote each line item separately.

The form requires contractors to affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions or companies. Contractors must disclose the 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 applies to both the primary contractor and any subcontractors utilized. Contractors have a continuing duty to disclose any changes or shifts in service locations before, during, and after contract execution and must notify the State immediately of such changes. 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 State provides a duly signed waiver.

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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:
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City State Zip:
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