STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D 2022-02D).pdf
PDF 124 KB Posted
- Attached to
- FY25 NODC Campus Landscaping State and local contract opportunity
- Solicitation number
- SRC0000029537
- Issued by
- Lucas County, Ohio
About this file
This document is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D and 2022-02D, applicable to state government contracts. The form requires contractors to affirm their understanding and compliance with specific prohibitions, including restrictions on performing offshore services, locating state data offshore, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location, locations where services will be performed, and locations where state data will be stored, both for the primary contractor and any subcontractors.
The form mandates ongoing disclosure of any changes in service locations before, during, and after contract execution, with the state retaining the right to immediately terminate the contract unless a signed waiver is obtained. Contractors must acknowledge their authorization to execute the form and understand that it is incorporated into any potential contract. The document emphasizes transparency about service locations and compliance with specific executive orders related to offshore services and the geopolitical context of Russian-associated business activities.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Contractor_Information_Form__rev._5.24_.pdf | ||
| NODC_FY25_Campus_Landscaping__Round_2.pdf | ||
| Electronic Disclosures and Signatures Consent.pdf | ||
| NODC FY25 Campus Landscaping.docx | DOCX document | |
| Contractor_Information_Form__rev._5.24_.pdf |
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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: ___________________________________
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