STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D__2022-02D___002__T._Scheidemantel.pdf
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- Attached to
- Agency Administered OH|CTR028865
- Contract number
- CTR028865
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form for Executive Orders 2019-12D and 2022-02D, governing the expenditure of public funds on offshore services and response to Russia's actions. The form is completed by a contractor located at 10524 Euclid Ave in Cleveland, Ohio, with a service location at 4325 Green Road in Highland Hills, Ohio. The document requires the contractor to affirm understanding of prohibitions related to offshore services, locating state data offshore, and purchasing from Russian institutions or companies.
The contractor, represented by Lisa Tripepi (Administrator), indicates that all services and state data will be performed and located at the 4325 Green Road address in Highland Hills, Ohio. No subcontractors are being used for this contract. The form emphasizes the contractor's obligation to immediately disclose any changes in service locations to the state, with the understanding that the state retains the right to terminate the contract if services are moved outside the United States without a signed waiver. The document is dated for execution on 7/3/2025 and is part of the contractor's commitment to compliance with specific executive orders regarding offshore services.
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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):
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: ___________________________________
| Address: 10524 Euclid Ave |
| City State Zip: Cleveland, OH 44106 |
| Name: Not Applicable |
| Address City State Zip: |
| Name_2: |
| Address City State Zip_2: |
| Address_2: 4325 Green Road |
| City State Zip_2: Highland Hills, OH 44128 |
| Name_3: Not Applicable |
| Address City State Zip_3: |
| Name_4: |
| Address City State Zip_4: |
| Address_3: 4325 Green Road |
| City State Zip_3: Highland Hills, OH 44128 |
| Name_5: |
| Address City State Zip_5: |
| Name_6: |
| Address City State Zip_6: |
| By: |
| Print Name: Lisa Tripepi |
| Title: Administrator |
| Date: 7/3/2025 |
File details come from the government source that posted it. Updated .