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
D06 - Crane Services Mansfield OH - RFQ-2134
Solicitation number
SRC0000041668
Issued by
Sandusky County, Ohio

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This is an Affirmation and Disclosure Form 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 specific contract opportunity is for crane services in Mansfield, Ohio (RFQ-2134), requiring a crane and operator rental with a working radius capable of setting 8' x 4' box culverts weighing up to 21,000 lbs. in a 30-foot wide trench. The project requires mobilization and demobilization of equipment, fuel, and support personnel, with work anticipated to begin around October 5, 2026, requiring a minimum of 12 hours of job time. Interested parties should contact Sam Morrison at 740-833-8023 to confirm the exact date.

Contractors must certify that all services will be performed and all state data will be located within the United States, with the state retaining the right to terminate the contract if services are performed or data is located outside U.S. borders without a signed waiver. Contractors have a continuing duty to disclose any changes or shifts in service locations before, during, and after contract execution and must notify the state immediately of any such changes. An authorized representative of the contractor must sign the form, certifying their authority to execute the agreement on behalf of the contractor.

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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:

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