Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

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Attached to
D01 Pressure Washer - Delphos State and local contract opportunity
Solicitation number
SRC0000029191
Issued by
Union County, Dayton City, Dayton City, Ohio

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Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form designed for a state government contract, requiring contractors to provide detailed information about their business locations, service performance sites, and data handling practices. The form mandates that contractors affirm their understanding of Executive Orders prohibiting offshore services, data storage outside the United States, and purchasing from Russian institutions or companies. Contractors must comprehensively disclose the names and locations of their principal business, service performance sites, and any subcontractors, as well as specify locations where state data will be accessed, tested, maintained, backed up, or stored.

The form emphasizes strict compliance with geographic restrictions, requiring contractors to immediately notify the state of any changes in service locations before, during, and after contract execution. The state retains the right to terminate the contract if any services are performed or data is located outside the United States without a signed waiver. Contractors must provide an authorized signature acknowledging their understanding that this disclosure is an integral part of any potential state contract, with a commitment to transparency regarding their operational and data management practices.

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Purchasing Standard Terms and Conditions - 03-2025.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:

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