E_Standard Affirmation & Disclosure Form_fillable PDF Form.pdf

267 KB Posted

Attached to
WMD2 Dormant Stem Herbicide Application - FY26
Solicitation number
SRC0000032031
Issued by
Hancock County, Ohio

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Written by GovTribe AI ·

This document is an Affirmation and Disclosure Form used by state government contractors to provide detailed location information for contract services. The form requires contractors to affirm that all services and data management will be performed within the United States, with any exceptions requiring a specific waiver from the state. Contractors must disclose their principal business location, locations where services will be performed, and locations where state data will be stored, including information about any subcontractors involved in the contract.

The form mandates ongoing transparency, requiring contractors to immediately notify the state of any changes in service or data location before, during, and after contract execution. The state retains the right to terminate the contract if services are moved outside the United States without proper authorization. Contractors must sign the document, acknowledging their understanding that this form is incorporated into the final contract and that they are legally bound to maintain the disclosed service and data locations throughout the contract period.

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Version 2/20 Page 1 of 2

AFFIRMATION AND DISCLOSURE FORM

By the signature affixed hereto, the Contractor affirms and understands that if awarded a contract, both the Contractor and any of its subcontractors shall perform no services requested under this Contract outside of the United States, nor allow State data to be sent, taken, accessed, tested, maintained, backed-up, stored or made available remotely (located) outside of the United States unless a duly signed waiver from the State has been attained.

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

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:

(Address) (City, State, Zip)

Name/Location where services will be performed by subcontractor(s):

Version 2/20 Page 2 of 2

3. Location where state data will be located, by Contractor:

(Address) (Address, City, State, Zip)

Name/Location(s) where state data will be located by subcontractor(s):

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 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 by the Contractor 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: __________________________________

Address:
City State Zip:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Name_3:
Name_4:
Address City State Zip_3:
Address City State Zip_4:
Address_3:
Address City State Zip_5:
Name_5:
Name_6:
Name_7:
Name_8:
Name_9:
Address City State Zip_6:
Address City State Zip_7:
Address City State Zip_8:
Address City State Zip_9:
Address City State Zip_10:

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