Affirmation_and_Disclosure_Form_Capital_Typing__1_.pdf
PDF 832 KB Posted
- Attached to
- Agency Administered OH|CTR030488
- Contract number
- CTR030488
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form issued by the Ohio Department of Job and Family Services in March 2022, in response to Executive Order 2022-020 regarding the State of Ohio's response to Russia's actions in Ukraine. The form is designed to ensure compliance with prohibitions on offshore services, state data location, and purchasing from Russian institutions. The contractor, located at 1627 Spur Branch Road #275 in Williston, South Carolina, is affirming their understanding and agreement to these terms.
The document does not specify specific goods or services under contract, but rather serves as a compliance mechanism for potential contractors. The form requires detailed disclosure of business locations, service performance locations, and data storage locations. The contractor must immediately notify the state of any changes in service or data location, with the understanding that the state retains the right to terminate the contract if services are performed outside the United States without a signed waiver. The form was signed by the CEO on 5/22/2025, indicating a future-dated agreement or preparation for a potential contract.
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Text version
OHIO DEPARTMENT OF JOB AND FAMILY
SERVICES
STANDARD AFFIRMATION AND DISCLOSURE
FORM
EXECUTIVE ORDER 2022-020
State of Ohio's Response to Russia's Unjust War on the Country of Ukraine
March 2022
All of the following provisions must be included in all invitations to bid, requests for proposals, state term schedules, multiple award contracts, requests for quotations, informal quotations, and statements of work. This information is to be submitted as part of the response to any of the procurement methods listed.
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.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
The Contractor shall provide all the name(s) and location(s) where services under this Contract will be performed and where data is located in the spaces provided below or by attachment. Failure to provide this information may result in no award. If the Contractor will not be using subcontractors, indicate "Not Applicable" in the appropriate spaces.
1627 Spur Branch Road #275 Williston, South Carolina 29853
1627 Spur Branch Road #275 Williston, South Carolina 29853
N/A
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
3. Location where state data will be located, by Contractor:
(Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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 it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside the United States.
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:
Contractor
1627 Spur Branch Road #275 Williston, South Carolina 29853
Print Name:
Title:
Date:
David Jonas
CEO
5/22/2025
File details come from the government source that posted it. Updated .