E_Standard Affirmation & Disclosure Form_fillable PDF Form.pdf
PDF 267 KB Posted
- Solicitation number
- SRC0000023996
- Issued by
- Warren County, Ohio
About this file
This document is an Affirmation and Disclosure Form that must be completed by a contractor and any subcontractors as part of a State contract. The form requires the contractor to affirm that all services will be performed, and data stored, within the United States unless a waiver is obtained. The contractor must provide the principal location of their business as well as the location(s) where services will be performed and where state data will be stored, both for the contractor and any subcontractors. The contractor also agrees to disclose any changes in the location of services or data storage during the contract term. Failure to complete this form accurately may result in no award of the contract.
The form does not provide details on the specific contract opportunity, such as the products or services requested, the project overview, quantities, response dates, award dates, contract term, or renewal options. There are also no details provided on pricing terms, set asides, incumbents, funding requirements, or other salient information 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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