Affirmation and Disclosure Form.pdf

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Attached to
Access Control, Patient Wandering, and Local Alarms Maintenance upkeep of Software and Hardware
Solicitation number
SRC0000031883
Issued by
Erie County, Ohio

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Written by GovTribe AI ·

This document is an Affirmation and Disclosure Form for a state contract that requires contractors to affirm compliance with Executive Orders regarding offshore services, data location, and prohibitions on purchasing from Russian institutions. The form mandates that contractors disclose the precise locations where all contract services will be performed and where state data will be accessed, tested, maintained, backed-up, or stored. Contractors must provide detailed location information for both their own operations and any subcontractors, with specific emphasis on ensuring all services and data remain within the United States.

The form explicitly states that contractors have a continuous duty to disclose any changes in service or data location before, during, and after contract execution, with the understanding that the state retains the right to terminate the contract if services are performed or data is located outside the United States without a signed waiver. Contractors must acknowledge their authorization to execute this form and recognize it as an integral part of the potential contract. The document includes provisions for multiple location entries, allowing flexibility for contractors with complex service delivery models while maintaining strict geographical compliance requirements.

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01 Model Contract 2025.doc DOC document
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Scope of Work 2.docx DOCX document

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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:

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