Affirmation__Disclosure__AD__Form.CEV.9.26.2025.pdf
PDF 1 MB Posted
- Attached to
- Agency Administered OH|CTR032992
- Contract number
- CTR032992
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form (Revision 3/22) completed by a contractor located at 1020 SE Loop 289 in Lubbock, TX 79404. The form requires the contractor to affirm understanding of Executive Orders prohibiting offshore services, locating state data offshore, and purchasing from Russian institutions or companies. The document mandates disclosure of business locations, service performance locations, and state data storage locations.
The contractor indicates that services will be performed at the same Lubbock, TX address as their principal business location, and state data will be stored in MS Azure South Central US. No subcontractors are listed on the form. The contractor, through the VP of Business Operations Bryce Moore, agrees to immediately notify the State of any changes in service or data location and acknowledges the State's right to terminate the contract if services are performed outside the United States without a signed waiver. The form is signed and dated for 9/26/2025, indicating a future contract or preparatory document.
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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):
bryce.moore Typewritten Text 1020 SE Loop 289 Lubbock, TX 79404 bryce.moore
1020 SE Loop 289 Lubbock, TX 79404
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:
bryce.moore
MS Azure South Central US bryce.moore Typewritten Text Bryce Moore bryce.moore Typewritten Text VP of Business Operations bryce.moore
9/26/2025
File details come from the government source that posted it. Updated .