Affirmation_and_Disclosure_Form.docxAffirmation_and_Disclosure_Form.docx
DOCX document 17 KB Posted
- Attached to
- PWC Barkcamp State Park Trail Boardwalk
- Solicitation number
- SRC0000038211
- Issued by
- Belmont County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Natural Resources for the Barkcamp State Park Trail Boardwalk construction project in Belmont, Ohio. The form establishes compliance requirements for contractors bidding on the project to construct a 6-foot wide, 100-foot long boardwalk on a hiking trail section between the overlook and beach. The project specifications require contractors to supply materials and labor using pressure-treated pine, 4"x4" or greater support posts set 36 inches deep in concrete column forms, and 2"x6" or greater decking fastened with outdoor-rated deck screws. The contractor is responsible for obtaining all required permits, removing and disposing of construction debris, and repairing any project area damage to previous or better condition. No specific response dates, due dates, site visits, bidder meetings, award dates, or contract term information is provided in this form.
The Affirmation and Disclosure Form requires contractors to affirm that all services and work will be performed within the United States and that state data will not be sent, accessed, tested, maintained, backed-up, stored, or made available outside the United States without a signed state waiver. Contractors must disclose the principal business location, subcontractor locations, service performance locations, and state data storage locations. The form explicitly prohibits the expenditure of public funds on services performed by Russian companies or institutions pursuant to Executive Order 2022-02D, and contractors must affirm that no contract services will be performed in Russia. Contractors are required to immediately notify the State of any changes in service location and understand that the State retains the right to immediately terminate the contract for violations unless a signed waiver is obtained. Pricing terms, funding sources, and set-asides are not addressed in this disclosure 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: | ___________________________________ |
File details come from the government source that posted it. Updated .