STANDARD AFFIRMATION AND DISCLOSURE FORM (EO 2019-12D & 2022-02D).pdf

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Mount Vernon Developmental Center - Cabinets for Lincoln
Solicitation number
SRC0000033908
Issued by
Lake County, Ohio

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This document is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D and 2022-02D, addressing offshore services and the response to Russia's actions. The form requires contractors to affirm their understanding of prohibitions on performing offshore services, locating state data offshore, or purchasing from Russian institutions or companies. Contractors must disclose the principal business location, locations where services will be performed, and where state data will be located, both for the primary contractor and any subcontractors.

The form obligates contractors to immediately notify the state of any changes in service locations before, during, and after contract execution. The state retains the right to terminate the contract unless a signed waiver is obtained for performing services outside the United States. The document requires an authorized representative of the contractor to sign and date the form, acknowledging that it will be incorporated into any contract with the department. The form is part of a broader effort to ensure transparency and compliance with specific executive orders regarding offshore services and international business practices.

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Contractor Information Form (rev. 5.24).pdf PDF
RFQ Document MVDC- cabinets_9.9.25.docx DOCX document

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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:
City State Zip:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Name_3:
Address City State Zip_3:
Name_4:
Address City State Zip_4:
Address_3:
City State Zip_3:
Name_5:
Address City State Zip_5:
Name_6:
Address City State Zip_6:
By:
Print Name:
Title:
Date:

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