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

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Attached to
(Rebid) D22 - Mailing & Collating for Aeronautical Charts (RFQ 2119)
Solicitation number
SRC0000040573
Issued by
Franklin County, Ohio

About this file

Written by GovTribe AI ·

This Affirmation and Disclosure Form is a standard compliance document required by the State of Ohio for contractors bidding on state contracts, specifically in connection with a rebid for mailing and collating services for aeronautical charts by the Ohio Department of Transportation (ODOT), Office of Aviation. The form requires contractors to affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions. Contractors must disclose the principal business location, all locations where services will be performed, and all locations where state data will be accessed, tested, maintained, backed-up, or stored. If subcontractors are utilized, their names and service/data locations must also be provided. The form emphasizes that contractors have a duty to disclose any changes or shifts in service locations before, during, and after contract execution, and must notify the state immediately of such changes. The state retains the right to terminate the contract if services are performed or state data is located outside the United States without prior written waiver.

The form serves as a binding component of any executed contract with the State of Ohio and requires authorization by a duly designated contractor representative through signature, printed name, title, and date. The fillable PDF format allows contractors to enter specific information regarding their operations and those of any subcontractors. Notably, the related RFQ specifies that presswork shall not be subcontracted, limiting the scope of allowable subcontracting. This document is essential for contract award and represents Ohio's commitment to ensuring all state services and data remain within U.S. borders and comply with national security and foreign policy directives.

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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 .