STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf

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Attached to
SODC Commercial Electric Steam Kettle 6 Gallon
Solicitation number
SRC0000037029
Issued by
Ohio

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This is a Standard Affirmation and Disclosure Form required by Executive Orders 2019-12D and 2022-02D for the State of Ohio related to a procurement for a commercial electric steam kettle. The form applies to a solicitation issued by the State of Ohio for one commercial grade electric 6-gallon steam kettle meeting specified minimum requirements. Contractors responding to this solicitation must complete and submit this form as part of their bid or proposal package.

The form requires contractors to disclose and affirm their compliance with state executive orders prohibiting the performance of offshore services, the locating of state data outside the United States, and the purchase of goods or services from Russian institutions or companies. Contractors must provide the principal location of their business, all locations where services will be performed, and all locations where state data will be stored, including information for any subcontractors. Contractors are obligated to immediately notify the State of any changes or shifts in service locations before, during, or after contract execution and must obtain a signed waiver from the State to perform services outside the United States. The State retains the right to immediately terminate the contract for non-compliance. The form must be signed by an authorized representative of the contractor and is incorporated as a binding part of any resulting contract.

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Contractor_Information_Form__rev._5.24_.pdf PDF
SODC- Steam Kettle 6 Gallons.pdf PDF

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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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