Affirmation___Disclosure__A_D__Form_Glenn.pdf
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- Attached to
- Agency Administered OH|403-24-3289A
- Contract number
- 403-24-3289A
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form (Revision 3/22) completed by a contractor located at 20 Brookline Ave. in Youngstown, Ohio 44505. The form is designed to affirm compliance with Executive Orders regarding offshore services, data location, and purchasing restrictions, specifically prohibiting services or data storage outside the United States or purchasing from Russian institutions or companies.
The form indicates that the contractor, whose representative is Brian Glenn with the title of School Psychologist, will perform services and locate state data at the same address (20 Brookline Ave., Youngstown, Ohio 44505). No subcontractors are listed on the form. The contractor agrees to immediately notify the state of any changes in service location and understands that the state can terminate the contract if services are moved outside the United States without a signed waiver. The document is signed with a projected contract date of 6-20-2025, suggesting this is part of a future state contract, potentially for school psychological services.
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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)
2. Location where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
Mobile User 20 Brookline Ave.
Mobile User Youngstown, Ohio 445055
Mobile User 20 Brookline Ave.
Mobile User Youngstown Ohio 44505
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:
20 Brookline Ave.
Mobile User Youngstown Ohio 44505
Mobile User Brian Glenn
Mobile User School Psychologist
6-20-2025
File details come from the government source that posted it. Updated .