Affirmation_and_Disclosure_Form_fillable_form.pdfAffirmation_and_Disclosure_Form_fillable_form.pdf
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- Attached to
- Four Polaris Ranger XP 1000 UTVs
- Solicitation number
- SRC0000040246
- Issued by
- Ohio
About this file
This is an Affirmation and Disclosure Form required by the State of Ohio for contractors entering into state contracts. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore storage of state data, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location of the contractor and all subcontractors, the locations where services will be performed by the contractor and subcontractors, and the locations where any state data will be accessed, tested, maintained, backed up, or stored. The form requires detailed information for up to two contractor locations and up to five subcontractor locations for each category of disclosure.
Contractors and subcontractors are under a continuing duty to disclose any changes or shifts in service performance locations before, during, and after contract execution and must notify the state immediately of any such changes. The state retains the right to terminate the contract if any services are performed or state data is located outside the United States unless the contractor obtains a duly signed waiver from the state. An authorized contractor representative must execute the form, certifying that they are duly authorized to do so and acknowledging that the form constitutes part of any resulting state contract.
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Text version
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: __________________________________
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