Affirmation_and_Disclosure_Form.pdf
PDF 230 KB Posted
- Attached to
- Agency Administered OH|CTR034626
- Contract number
- CTR034626
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form, revised in March 2022, involving a contractor located in Ohio. The form requires disclosure of business locations, service performance sites, and state data storage locations. The contractor affirms understanding of Executive Orders prohibiting offshore services, offshore data storage, and purchasing from Russian institutions or companies.
The contractor has three primary locations: 2900 Newpark Drive in Barberton, OH 44203 (principal business location), 2400 Avon Belden Road in Grafton, OH 44044 (service performance location), and 135 Alpha Park in Highland Heights, OH 44143 (state data location). The form indicates no subcontractors will be used, and the contractor has committed to immediately notify the State of any changes in service or data locations. The document is signed by Vanessa Mihelich, Manager of Contracts/Insurance, with an execution date of 11/24/2025, and grants the State the right to terminate the contract if services are performed outside the United States without a signed waiver.
View the file
Other files
| File | Type | Posted |
|---|---|---|
| ACCORD_10_01_26.pdf | ||
| Auditor_of_State_of_Ohio_-_Certified_Search_-_Findings_for_Recovery_-_SA_Comunale.pdf | ||
| BWC_07_01_26.pdf |
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
AFFIRMATION AND DISCLOSURE FORM
Rev. 3/22 Page 1 of 2
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.
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.
1. Principal location of business of Contractor:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
2900 Newpark Drive Barberton, OH 44203
2400 Avon Belden Road Grafton, OH 44044
Not Applicable
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
Contractor 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 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
Print Name:
Title:
Date:
135 Alpha Park Highland Heights, OH 44143
Vanessa Mihelich
Manager, Contracts/Insurance
11/24/2025
File details come from the government source that posted it. Updated .