STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdfSTANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D_.pdf
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- Solicitation number
- SRC0000040940
- Issued by
- Cuyahoga County, Ohio
About this file
This is a Standard Affirmation and Disclosure Form required under Ohio Executive Orders 2019-12D and 2022-02D for the Warrensville Developmental Center underground and above ground natural gas lines repair and replacement project in Highland Hills, Ohio. The form establishes compliance requirements for contractors regarding the prohibition of offshore services, offshore data location, and purchasing from Russian institutions or companies. Contractors must disclose all locations where services will be performed, including all subcontractor locations, and the locations where any state data will be stored or maintained. The form requires contractors to identify their principal business location, all subcontractor principal locations, service performance locations, and data storage locations in the spaces provided or through attachment documentation.
Contractors and their subcontractors are under a contractual duty to immediately notify the State of any changes or shifts in service locations before, during, and after contract execution. The State reserves the right to immediately terminate the contract if services are performed outside the United States without obtaining a duly signed waiver from the State in advance. The person executing the form must be duly authorized on behalf of the contracting entity and must acknowledge that the completed affirmation and disclosure form becomes part of and is incorporated into any resulting contract with the State. Failure to provide complete location information may result in the contractor receiving no award for the solicitation.
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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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