E_Standard Affirmation & Disclosure Form.pdf
PDF 84 KB Posted
- Attached to
- Woody Corridor Mgt at Wyandot WAs - FY2025
- Solicitation number
- SRC0000023068
- Issued by
- Wayne County, Ohio
About this file
This document is a state of Ohio Affirmation and Disclosure Form for contractors providing services under a state contract. It requires the contractor to disclose the locations where the services will be performed and where any state data will be located, including any subcontractors. The contractor must affirm they have read and understand the applicable Executive Orders regarding prohibitions on offshore services and purchasing from Russian entities. The contractor must notify the state of any changes to the location of services during the contract.
The related state and local contract opportunity is for the management (e.g. tree cutting and removal) of large trees in woody corridors at Wyandot and Willard Marsh Wildlife Areas in Wyandot and Huron Counties, Ohio. The contract is for fiscal year 2025. No other details about the contract opportunity such as quantities, response dates, award dates, or contract term are provided.
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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):
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:
File details come from the government source that posted it. Updated .