Affirmation_and_Disclosure_Form_fillable_form.pdfAffirmation_and_Disclosure_Form_fillable_form.pdf

PDF 103 KB Posted Jul 6, 2026

Attached to: Epoxy Floor installation at Lake Hope State Park Shower House #2/Laundry Area
Solicitation number: SRC0000040191
Issued by: Ohio

About this file

Written by GovTribe AI · Sep 18, 2026

This is an Affirmation and Disclosure Form required by the State of Ohio for contractors bidding on the Epoxy Floor installation project at Lake Hope State Park Shower House #2/Laundry Area. The form serves as a compliance document wherein contractors must affirm their understanding of and adherence to Executive Orders prohibiting offshore service performance, offshore State data location, and procurement from Russian institutions or companies. Contractors are required to disclose the principal business location of the contracting entity, all locations where services will be performed, and all locations where State data will be accessed, tested, maintained, backed-up, or stored. The form accommodates disclosure of subcontractor information across multiple locations.

Contractors must affirm their commitment to notify the State of any changes or shifts in service locations before, during, or after contract execution and agree that the State retains the right to terminate the contract if services are performed or State data is located outside the United States without a duly signed State waiver. The form requires authorization by a duly authorized representative of the contractor, including signature, printed name, title, and date. All disclosed locations must be within the United States unless an explicit waiver has been obtained from the State in advance of contract performance.

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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:

File details come from the government source that posted it. Updated Sep 18, 2026.