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
Evaluation Consultant
Solicitation number
SRC0000041420
Issued by
Franklin County, Ohio

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This is an Affirmation and Disclosure Form (Version 5/24) required by the State of Ohio for contractors bidding on the Evaluation Consultant opportunity with ServeOhio. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchasing from Russian institutions or companies. 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. The form requires identification of any subcontractors and their respective service and data locations. ServeOhio seeks an evaluation consultant to provide capacity building and technical assistance related to AmeriCorps' Evidence Framework from October 15, 2026 through May 31, 2027, with required attendance at the Winter Program Director meeting in Columbus, Ohio on January 28, 2027.

Contractors and their subcontractors must commit to disclosing any changes or shifts in service location before, during, and after contract execution and notify the State immediately of such changes. The State reserves the right to terminate the contract if any services are performed or State data is located outside the United States unless a duly signed waiver is obtained from the State. All materials developed under the contract, including instruments, reports, and visuals, become the exclusive property of ServeOhio and cannot be used or disseminated by the contractor without express written consent. The form requires authorized contractor signature, printed name, title, and date of execution to be incorporated as a binding part of any resulting contract with the State.

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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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