Affirmation_and_Disclosure_Form_ODOT.pdf
PDF 204 KB Posted
- Attached to
- Competitive Selection OH|DOT21525-2
- Contract number
- DOT21525-2
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form for a state contract, specifically related to the Ohio Department of Transportation (ODOT). The primary contractor is located at 661 Highland Avenue in Mansfield, Ohio 44903, with one identified subcontractor, Nuhaus Outdoors, based at 7280 Kidron Rd. in Apple Creek, Ohio 44606. The form requires the contractor to affirm compliance with executive orders regarding offshore services, data location, and prohibitions on purchasing from Russian institutions or companies.
The form details the locations where services will be performed and where state data will be located, both by the primary contractor and the subcontractor. Both entities will operate from their respective Ohio addresses. The document emphasizes the contractor's obligation to disclose any changes in service locations to the state, with the understanding that the state retains the right to immediately terminate the contract if services are proposed to be performed outside the United States without a signed waiver. The form was signed by Shavontia S. Lee in the capacity of Director on 09/17/2024, indicating an upcoming or ongoing contract period.
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Other files
| File | Type | Posted |
|---|---|---|
| Signature.pdf | ||
| 215-25_Bid_Document.pdf | ||
| 215-25_Pricing_odot.xlsx | XLSX spreadsheet |
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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)
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
661 Highland avenue Mansfield, OH 44903
7280 Kidron Rd.
Apple Creek, OH 44606
Nuhaus Outdoors 7280 Kidron Rd.
Apple Creek, OH 44606
661 HIGHLAND AVENUE Mansfield, OH 44903
Nuhaus Outdoors
Rev. 3/22 Page 2 of 2
3. Location where state data will be located, by Contractor:
(Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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:
7280 Kidron Rd.
Apple Creek, OH 44606Nuhaus Outdoors
Mansfield, OH 44903661 HIGHLAND AVENUE
Shavontia S. Lee
Director
09/17/2024
File details come from the government source that posted it. Updated .