STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D__rev._3-2022.pdf
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- Attached to
- Agency Administered OH|CTR030357
- Contract number
- CTR030357
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D & 2022-02D, which governs the expenditure of public funds on offshore services and response to Russia's actions. The form is completed by a contractor located at 100 E. Campus Blvd. Suite 250 in Columbus, Ohio 43235, and is designed to affirm compliance with specific governmental requirements regarding service locations and data handling.
The contractor indicates that services will be performed at Warrensville DC - 4325 Green Road in Highland Hills, OH 44128, with no offshore subcontractors or data storage locations identified. The form requires the contractor to disclose any changes in service locations before, during, and after contract execution, with the understanding that the state retains the right to immediately terminate the contract unless a waiver is obtained for services performed outside the United States. The document was signed by the owner, Yolanda Long, with an execution date of July 22, 2025.
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Other files
| File | Type | Posted |
|---|---|---|
| Contract_Addendum_B_-_Direct_Services_Positions.pdf | ||
| CTR030357_-_Mane_Consulting__WDC_.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)
(Name) (Address, City, State, Zip)
2. Location(s) where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
3. Location where state data will be located, by Contractor:
(Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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: ___________________________________
| 0lLocumro6sC: | |
| 2I1FXvwMuaY5: Highland Hills, OH 44128 | |
| 7vjIwGh8FrI6: N/A | |
| 9CDPrbqPx9c9: | |
| Bu9SMGEElgkI: N/A | |
| ceAJMaaBWx8J: Columbus Ohio 43235 | |
| DeEf8RMi1IsM: | |
| e0kKIuKR8cYN: | |
| ezvq1IC6uas0: | |
| i3aQCd8OJMYR: | |
| JzmIbNKnnZo7: | |
| rywWEDIypVE8: 100 E. Campus View Blvd. Suite 250 | |
| teIBtP7gmx8U: | |
| Tq62FZqAAdcF: | |
| UuCZkmpSDw47: | |
| VkPBG475UyMR: | |
| Wqmw0RqVFXMR: | |
| y134HkjhDnIX: Warrensville DC - 4325 Green Road | |
| MVVuM0g3DMgL_QrDxZspIQjsR: Yolanda Long | |
| MVVuM0g3DMgL_JPzar1MhU68F: Owner | |
| MVVuM0g3DMgL_PLLxiCDEsyAD: 2025-07-22 12:21:02 | |
| 2025-07-22T16:21:04+0000 | |
| Client IP: 74.137.134.250, Transaction ID: uGpuhiIqL_RFTsKbhfQuDXMI4_8= | |
| OneSpan | |
| E-SIGNED by Yolanda Long (yolandamlong1@gmail.com), ID: c03e39f6-2f06-493b-94a3-55e7be1c5843 |
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