Affirmation_and_Disclosure_Form.docx
DOCX document 17 KB Posted
- Attached to
- PWC Barkcamp Trail Boardwalk
- Solicitation number
- SRC0000037868
- Issued by
- Belmont County, Ohio
About this file
This Affirmation and Disclosure Form is required by the Ohio Department of Natural Resources for the Barkcamp Trail Boardwalk construction project at Barkcamp State Park in Belmont County, Ohio. The form requires contractors and their subcontractors to affirm that all services will be performed within the United States and that state data will not be sent, accessed, stored, or maintained outside the United States without a signed waiver from the State. Contractors must disclose the principal business location, all locations where services will be performed, and all locations where state data will be stored. The form mandates compliance with Executive Order 2022-02D, which prohibits the expenditure of public funds on services performed by Russian companies or institutions, in addition to the existing prohibition on offshore services under Executive Order 2019-12D. Contractors are required to immediately notify the State of any changes or shifts in service locations before, during, or after contract execution, and the State reserves the right to immediately terminate the contract if services are performed outside the United States without prior written waiver.
Contractors must complete and sign the Affirmation and Disclosure Form as a condition of contract award, acknowledging authorization to execute the document and understanding that the form becomes incorporated into any resulting contract. The form requires disclosure of subcontractor information and locations, with the contractor bearing the responsibility to ensure all subcontractors comply with the same locational and Russia-related restrictions. Failure to provide complete location information may result in no award. The State of Ohio specifically reserves the right to recover any funds paid for services performed in violation of the Executive Order restrictions and retains all other rights and remedies available under the contract.
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Other files
| File | Type | Posted |
|---|---|---|
| Barkcamp Boardwalk RFQ.docx | DOCX document | |
| Independent Contractor-Worker Acknowledgement Form (PEDACKN).pdf | ||
| Standard_T_C_3-31-25.pdf | ||
| Ohio Supplier and Bidder Support.pdf | ||
| Addendum to Bid Quote Base Template (Non-Federal Funds)_Rev. 2025 11 28_NO GUIDANCE (1).docx | DOCX document |
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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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