STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf

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Attached to
MVDC Maintenance Building Roof Repair
Solicitation number
SRC0000036747
Issued by
Ohio

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This is a Standard Affirmation and Disclosure Form required under Ohio Executive Orders 2019-12D and 2022-02D for the MVDC Maintenance Building Roof Repair project at Mount Vernon Developmental Center. The form serves as a compliance document that contractors must complete and submit as part of their bid or contract execution. Contractors are required to disclose all locations where services will be performed, identify any subcontractors and their service locations, and specify where state data will be stored or located. The form mandates that all work be performed within the United States unless the contractor obtains a signed waiver from the State, and it explicitly prohibits offshore services, offshore data storage, and procurement from Russian institutions or companies.

Contractors must affirm their understanding of these executive orders and acknowledge their obligation to immediately notify the State of any changes or shifts in service locations before, during, or after contract execution. Failure to provide complete location information may result in no award of the contract. The State reserves the right to immediately terminate any contract if services are relocated outside the United States without prior written authorization. By signing the form, an authorized representative of the contractor confirms they have read and understand these requirements and that the affirmation is incorporated into any resulting contract with the State.

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Contractor_Information_Form__rev._5.24_.pdf PDF
Contractor_Certification_Statements.pdf PDF
Maintenance Building Roof Repair RFQ Document.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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