Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

PDF 103 KB Posted

Attached to
PWC Hocking Hills Grapple State and local contract opportunity
Solicitation number
SRC0000030638
Issued by
Hocking County, Ohio

About this file

Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form designed for state government contract compliance, specifically addressing executive orders related to offshore services and data location restrictions. The form requires contractors to disclose detailed location information about their business operations, service performance sites, and the specific locations where state data will be accessed, tested, maintained, backed up, or stored. Contractors must provide comprehensive details about their principal business locations, potential subcontractor locations, and explicitly affirm that they understand prohibitions on performing services offshore or using Russian institutions or companies.

The form emphasizes strict geographical requirements, mandating that all services and state data must be located within the United States unless a formal waiver is obtained from the state. Contractors are obligated to continuously disclose any changes in service or data location before, during, and after contract execution, with the state retaining the right to terminate the contract if services are performed outside the United States. The document includes a certification section where an authorized contractor representative must sign, acknowledging their understanding that this disclosure is an integral part of any potential state contract and that they are bound by the specified geographic and operational restrictions.

View the file

Other files for this state and local contract opportunity

Other files attached to PWC Hocking Hills Grapple, newest first.
File Type Posted
DAS Standard_T_C_3-31-25.pdf PDF
Hocking Grapple RFQ.pdf PDF
OhioBuys FAQs for Suppliers.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 .