Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf
PDF 103 KB Posted
- Attached to
- D01 Ditch Cleaning - Putnam State and local contract opportunity
- Solicitation number
- SRC0000028736
- Issued by
- Putnam County, Ohio
About this file
This document is an Affirmation and Disclosure Form related to a state contract that requires contractors to disclose the geographic locations where services will be performed and where state data will be accessed, maintained, or stored. The form mandates that contractors affirm they understand executive orders prohibiting offshore services, offshore data storage, and purchasing from Russian institutions. Contractors must provide comprehensive details about their principal business locations, service performance locations, and data handling locations, including information about any subcontractors involved in the contract.
The form emphasizes strict compliance with geographic restrictions, giving the state the right to terminate the contract if services are performed or data is located outside the United States without a signed waiver. Contractors are obligated to immediately disclose any changes in service or data location before, during, and after contract execution. The document requires an authorized contractor representative to sign, acknowledging understanding of these terms and affirming that the disclosure is an integral part of any potential contract with the state. The form serves as a critical mechanism for ensuring transparency, security, and compliance with state regulations regarding service delivery and data management.
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Text version
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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