STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf
PDF 124 KB Posted
- Attached to
- GDC FY26 Outdoor Rubber Surfacing Area State and local contract opportunity
- Solicitation number
- SRC0000036295
- Issued by
- Gallia County, Ohio
About this file
This is a Standard Affirmation and Disclosure Form required under Executive Orders 2019-12D and 2022-02D, applicable to state and local contract opportunities. The form mandates that contractors affirm their compliance with prohibitions on offshore services performance, locating state data offshore, and purchasing from Russian institutions or companies. Contractors must disclose the principal business location, all locations where services will be performed, and all locations where state data will be located, including information for any subcontractors utilized. The form requires detailed identification of each service location and data storage location by address, city, state, and zip code, with failure to provide this information potentially resulting in no contract award.
Contractors and their subcontractors are obligated to immediately notify the state of any changes or shifts in service locations before, during, or after contract execution. The state retains the right to terminate the contract immediately if services are performed outside the United States without obtaining a duly signed waiver from the state. The form must be executed by a duly authorized representative of the contractor, who certifies understanding that the affirmation and disclosure form constitutes part of any resulting contract with the state and is incorporated within its terms. This document serves as a compliance and transparency mechanism ensuring adherence to executive order requirements regarding data protection and geopolitical procurement restrictions.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| GDC - Rubber Surfacing RFQ.docx | DOCX document | |
| Contractor_Certification_Statements.pdf | ||
| 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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