Complete_with_Docusign_STANDARD_AFFIRMATION___1_.pdf
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- Attached to
- Agency Administered OH|CTR029410
- Contract number
- CTR029410
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form for Executive Orders 2019-12D & 2022-02D, pertaining to the expenditure of public funds on offshore services and response to Russia's actions. The form is associated with The Ohio State University, specifically the Nisonger Center, located at 1581 Dodd Dr in Columbus, OH 43210. The document is designed to affirm compliance with specific executive orders prohibiting offshore services, locating state data offshore, or purchasing from Russian institutions or companies.
The form confirms that all services and state data will be performed and located at the same address in Columbus, OH, with no subcontractors involved. The document was signed by Marc J. Tassé, PhD, Director of the Nisonger Center, on 07/23/2025, and electronically processed through DocuSign. The contractor affirms an ongoing duty to disclose any changes in service location to the state, with the understanding that the state reserves the right to immediately terminate the contract unless a specific waiver is obtained to perform services outside the United States.
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| OSU__FRNO_Contract_CTR029410_executed.pdf |
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Text version
STANDARD AFFIRMATION AND DISCLOSURE FORM
EXECUTIVE ORDERS 2019-12D & 2022-02D
EO2019-12D & 2022-02D Form (rev. 3 2022)
Governing the Expenditure of Public Funds on Offshore Services & Response to Russia’s Unjust War
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 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(s) where services will be performed by Contractor:
Name/Location where services will be performed by subcontractor(s):
3. Location where state data will be located, by Contractor:
Name/Location(s) where state data will be located by subcontractor(s):
1581 Dodd Dr Columbus, OH 43210
Docusign Envelope ID: DD3E9247-888A-4557-8616-ECBD1D9128D5
STANDARD AFFIRMATION AND DISCLOSURE FORM
EXECUTIVE ORDERS 2019-12D & 2022-02D
EO2019-12D & 2022-02D Form (rev. 3 2022)
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 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 by the Contractor to perform the services outside of 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 Department and is incorporated therein.
By: ____________________________________
Print Name: _____________________________
Title: ___________________________________
Date: ___________________________________
Marc J Tassé, PhD Director, Nisonger Center
Docusign Envelope ID: DD3E9247-888A-4557-8616-ECBD1D9128D5
07/23/2025
Certificate Of Completion Envelope Id: DD3E9247-888A-4557-8616-ECBD1D9128D5 Status: Completed
Subject: Complete with Docusign: STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D 2022-02D) (002).pdf
Source Envelope:
Document Pages: 2 Signatures: 1 Envelope Originator:
Certificate Pages: 1 Initials: 0 Jyunichi Yamada
AutoNav: Enabled
EnvelopeId Stamping: Enabled
Time Zone: (UTC-05:00) Eastern Time (US & Canada)
1050 Carmack Rd
Columbus, OH 43210 yamada.57@osu.edu
IP Address: 140.254.70.174
Record Tracking Status: Original
7/22/2025 2:09:44 PM
Holder: Jyunichi Yamada yamada.57@osu.edu
Location: DocuSign
Signer Events Signature Timestamp Marc J. Tassé tasse.1@osu.edu
The Ohio State University
Security Level: Email, Account Authentication (None) Signature Adoption: Pre-selected Style
Using IP Address: 75.118.53.126
Sent: 7/22/2025 2:10:53 PM
Viewed: 7/23/2025 5:44:06 AM
Signed: 7/23/2025 5:44:18 AM
Electronic Record and Signature Disclosure:
Not Offered via Docusign
In Person Signer Events Signature Timestamp
Editor Delivery Events Status Timestamp
Agent Delivery Events Status Timestamp
Intermediary Delivery Events Status Timestamp
Certified Delivery Events Status Timestamp
Carbon Copy Events Status Timestamp
Witness Events Signature Timestamp
Notary Events Signature Timestamp
Envelope Summary Events Status Timestamps Envelope Sent Hashed/Encrypted 7/22/2025 2:10:53 PM
Certified Delivered Security Checked 7/23/2025 5:44:06 AM
Signing Complete Security Checked 7/23/2025 5:44:18 AM
Completed Security Checked 7/23/2025 5:44:18 AM
Payment Events Status Timestamps
| 2025-07-24T07:32:37-0700 | |
| Digitally verifiable PDF exported from www.docusign.com |
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