Affirmation_and_Disclosure_Form.docx
DOCX document 17 KB Posted
- Solicitation number
- SRC0000038207
- Issued by
- Warren County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Transportation (ODOT) for the ambulance service contract solicitation issued by Lebanon Correctional Institution (LeCI), a state facility operated by the Ohio Department of Rehabilitation and Correction. The form mandates that contractors and their subcontractors perform all services exclusively within the United States and ensure that all state data remains located within U.S. borders unless the State provides a signed waiver. Contractors must identify their principal business location, the specific locations where services will be performed, and the locations where state data will be stored, with provisions for both direct contractor operations and subcontractor arrangements. The form requires contractors to disclose any changes to service locations before, during, or after contract execution and obligates them to notify the State immediately of such changes, with the State retaining the right to terminate the contract unless a waiver is obtained. The procurement was posted on April 6, 2026, with a response deadline of April 21, 2026.
The form incorporates Executive Order 2022-02D, which prohibits all state agencies from purchasing services from Russian companies or institutions. Contractors must affirm that neither they nor their subcontractors will perform any services under the contract in Russia and must complete the attached Exhibit II, Contractor/Subcontractor Affirmation and Disclosure Form as a binding part of the contract. The State reserves the right to recover any funds paid for services performed in Russia in violation of this Executive Order. Authorized company representatives must sign and date the form, certifying their authority to execute it and acknowledging full understanding that this affirmation becomes an integrated component of any resulting contract award.
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| File | Type | Posted |
|---|---|---|
| Independent Contractor-Worker Acknowledgement Form (PEDACKN).pdf | ||
| Ambulance RFQ BLANK - FY 2027.docx | DOCX document | |
| Standard_T_C_3-31-25.pdf |
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Text version
AFFIRMATION AND DISCLOSURE FORM
By the signature affixed hereto, the Contractor affirms and understands that if awarded a contract, both the Contractor and any of its subcontractors shall perform no services requested under this Contract outside of the United States, not allow State data to be sent, taken, accessed, tested, maintained, backed-up, stored or made available remotely(located) outside of the United States unless a duly signed waiver from the State has been attained.
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.
EXPENDITURE OF PUBLIC FUNDS ON SERVICES PERFORMED BY RUSSIAN COMPANIES OR INSTITUTIONS.
The Contractor affirms to have read and understands Executive Order 2022-02D and shall abide by those requirements in the performance of this Contract. Pursuant to this Executive Order, all state agencies are prohibited from the purchase of services from Russian companies or institutions. This prohibition is in addition to and expands upon Executive Order 2019-12D which generally precludes the purchase of offshore services by the State of Ohio. Notwithstanding any other terms of this Contract, ODOT reserves the right to recover any funds paid for services the Contractor performs in Russia in violation of this Executive Order. ODOT does not waive any other rights and remedies provided to ODOT in this Contract.
The Contractor agrees to complete the attached Exhibit II, Contractor/Subcontractor Affirmation and Disclosure Form, to abide with Executive Order 2022-02D, which is incorporated and becomes a part of this Contract, affirming no services of the Contractor or its subcontractors under this Contract will be performed in Russia.
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):
| ___________________________________ | _________________________________ | |
| (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) |
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.
Signature:
Contractor Print Name: _______________________________
| Title: | ___________________________________ |
| Date: | ___________________________________ |
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