Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

PDF 103 KB Posted

Attached to
D22 - Econolite Video Detection State and local contract opportunity
Solicitation number
SRC0000030118
Issued by
Ohio

About this file

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form designed for contractors engaging with a state government contract. The form requires contractors to disclose detailed information about their business locations, service performance locations, and data storage sites, with specific emphasis on compliance with Executive Orders prohibiting offshore services, data storage, and purchases from Russian institutions or companies. Contractors must provide comprehensive details about their principal business locations, subcontractor locations, and specific addresses where services will be performed and state data will be accessed, tested, maintained, backed-up, or stored.

The form mandates ongoing transparency, requiring contractors to immediately disclose any changes in service or data location 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, unless a signed waiver is obtained. By executing this form, the contractor acknowledges understanding these requirements and agrees to immediate notification of any location shifts. The document includes a signature section for an authorized contractor representative to confirm compliance and understanding of these critical geographic and operational disclosure obligations.

View the file

Other files for this state and local contract opportunity

Other files attached to D22 - Econolite Video Detection, newest first.
File Type Posted
Purchasing Standard Terms and Conditions - 03-2025.pdf PDF

On GovTribe

Work with this file on GovTribe

  • Download the original file
  • Contacts named in this file
  • Similar government files
  • Ask GovTribe AI about this file
Try for free Login

Text version

The file's text, extracted by GovTribe without its formatting.

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 .