Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

104 KB Posted

Attached to
Walking Path Resurfacing and Culvert replacement
Solicitation number
SRC0000026220
Issued by
Butler County, Ohio

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This is an Affirmation and Disclosure Form from an Ohio state agency requiring contractors to affirm compliance with Executive Orders regarding prohibitions on offshore services, state data storage locations, and purchasing from Russian institutions. The form is dated version 5/24 and is associated with a walking path resurfacing and culvert replacement project at the Ohio Veterans Home-Georgetown, which involves approximately 3,800 linear feet of 10-foot wide path at 2003 Veterans Blvd, Georgetown OH 45121. A mandatory site visit is scheduled for 01/07/25 at 10:00 AM.

The form requires contractors to disclose detailed information about their principal business locations, subcontractor locations, service performance locations, and state data storage locations - all of which must be within the United States unless a state waiver is obtained. The form requires authorized contractor signature and becomes part of any contract entered into with the State. Non-compliance or unauthorized relocation of services can result in contract termination.

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Other files

File Type Posted
Certification Statement.pdf PDF
SOW Walking path.docx DOCX document
Contractor Information Form.pdf PDF
Contractor Information Form.pdf PDF
SOW Walking path.docx DOCX document
Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf PDF
Certification Statement.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:

File details come from the government source that posted it. Updated .