E_Standard Affirmation & Disclosure Form_fillable PDF Form.pdf
PDF 267 KB Posted
- Attached to
- Woody Corridor Mgt at Wyandot WAs - FY2025
- Solicitation number
- SRC0000023068
- Issued by
- Wayne County, Ohio
About this file
The document is an Affirmation and Disclosure Form required for a state and local government contract opportunity. It requires the contractor to affirm that they will perform all services and hold all data within the United States, and to disclose the locations where services will be performed and data will be stored. The contractor must also agree to notify the state of any changes in the location of services during the contract. Failure to provide this information or obtain a waiver may result in no award of the contract.
The document does not provide details about the specific contract opportunity, such as the products or services requested, project overviews, quantities, response dates, award dates, contract term, or renewal options. It also does not include information about pricing, set asides, incumbents, funding requirements, or other salient details related to the contract opportunity.
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Text version
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: __________________________________
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