Affirmation__Disclosure__AD__Form.pdf
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- Attached to
- Agency Administered OH|403-24-3277E
- Contract number
- 403-24-3277E
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form from a contractor located at 1467 Mt. Vernon Avenue in Marion, Ohio 43302. The form affirms the contractor's understanding of Executive Orders regarding prohibitions on offshore services, offshore data storage, and purchasing from Russian institutions. The contractor provides details about their principal business location and service performance location, both of which are in Marion, Ohio. No subcontractors are identified in the document.
The form requires the contractor to disclose the locations where services will be performed and where state data will be located, which in this case is the same address: 1467 Mt. Vernon Avenue in Marion, Ohio 43302. The contractor agrees to immediately notify the State of any changes in service locations 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 by Dr. Bob Haas, Provost and Chief Strategy Officer, on June 14, 2025, acknowledging these terms and conditions.
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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):
1467 Mt. Vernon Avenue Marion, Ohio 43302
940 Marion Williamsport Rd E Marion, Oh 43302
N/A
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:
1467 Mt. Vernon Avenue Marion, Ohio 43302
Dr. Bob Haas
Provost and Chief Strategy Officer
June 14, 2025
File details come from the government source that posted it. Updated .