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

PDF 103 KB Posted Aug 12, 2026

Attached to: PWC- Dillon Fuel Tank Repairs
Solicitation number: SRC0000041232
Issued by: Montgomery County, Ohio

About this file

Written by GovTribe AI · Sep 22, 2026

This is an Affirmation and Disclosure Form, version 5/24, required for contractors bidding on state contracts with the Ohio Department of Natural Resources for the Dillon State Park Fuel Tank Repairs project. The form serves as a compliance document in which contractors must affirm their understanding of executive orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions or companies. Contractors are required to disclose the principal business location of their company, all locations where services will be performed, and all locations where state data will be accessed, tested, maintained, backed-up, or stored. If subcontractors will be utilized, their names and service locations must also be disclosed in the designated spaces provided on the form.

The form emphasizes that both contractors and subcontractors maintain an ongoing duty to disclose any changes or shifts in service performance locations before, during, and after contract execution, with immediate notification required to the state. Contractors must affirm that all services and state data locations are confined to the United States, with the state reserving the right to terminate the contract if services are performed or data is located outside U.S. boundaries without a duly signed waiver. The authorized contractor representative must execute the form by providing a signature, printed name, title, and date, acknowledging that the completed affirmation and disclosure form becomes an incorporated component 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:

File details come from the government source that posted it. Updated Sep 22, 2026.