Affirmation_and_Disclosure_Form_fillable_form.pdfAffirmation_and_Disclosure_Form_fillable_form.pdf
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- Solicitation number
- SRC0000041657
- Issued by
- Franklin County, Ohio
About this file
This is an Affirmation and Disclosure Form required by the Ohio Department of Natural Resources, Division of Parks and Watercraft for a Skydio X10-VT300Z drone procurement. The form mandates that contractors affirm compliance with Executive Orders prohibiting offshore service performance, offshore data location, and purchases from Russian institutions or companies. Contractors must disclose all principal business locations, locations where services will be performed, locations where subcontractors will perform services, and all locations where State data will be accessed, tested, maintained, backed up, or stored. The procurement involves one Skydio X10-VT300Z drone system with accessories, Skydio RTK/PPK for X10, and three-year Skydio Care coverage with Cellular 5G and VT300-Z support. All items must be new, not used, and the supplier must be an approved and authorized Skydio dealer within the United States. The place of performance is Columbus, Ohio at the ODNR Division of Parks and Watercraft, 2045 Morse Road, Building A-2.
Contractors and their subcontractors are under a continuing duty to disclose any changes or shifts in service 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 State provides a duly signed waiver. The authorized contractor representative executing this form must acknowledge they are duly authorized and understand that this affirmation and disclosure form becomes part of and is incorporated into any resulting contract with the State.
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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: __________________________________
File details come from the government source that posted it. Updated .