Affirmation_and_Disclosure_Form_5-20-24_fillable_form.pdfAffirmation_and_Disclosure_Form_5-20-24_fillable_form.pdf

103 KB Posted

Attached to
D06 - Light Poles - RFQ 2121
Solicitation number
SRC0000040188
Issued by
Delaware County, Ohio

About this file

Written by GovTribe AI ·

This is an Affirmation and Disclosure Form (Version 5/24) required by the State of Ohio for contractors entering into state contracts. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore service performance, locating state data offshore, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location of the contractor and any subcontractors, all locations where services will be performed, and all locations where state data will be accessed, tested, maintained, backed up, or stored. The form explicitly states that contractors and subcontractors have a duty to disclose any changes or shifts in service locations before, during, and after contract execution, with immediate notification required to the state. The state retains the right to terminate the contract if any services are performed or state data is located outside the United States unless the contractor obtains a duly signed waiver from the state.

The form serves as a binding document incorporated into any contract entered with Ohio and must be signed by an authorized contractor representative. Contractors must provide detailed information across multiple disclosure sections for both prime contractors and all subcontractors involved in service delivery or data handling. The authorized signatory must print their name, title, and date the form, confirming they are duly authorized to execute the affirmation on behalf of the contractor. Failure to comply with the requirements outlined in this form or the underlying Executive Orders regarding offshore prohibitions and Russian company restrictions constitutes a material breach of the contract terms.

View the file

Other files

File Type Posted
Office of Contracts.IT.Finance Purchasing Standard Terms and Conditions 5.26.2026.pdfOffice of Contracts.IT.Finance Purchasing Standard Terms and Conditions 5.26.2026.pdf PDF

On GovTribe

Work with this file

  • 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 .