STANDARD_AFFIRMATION_AND_DISCLOSURE_FORM__EO_2019-12D___2022-02D__rev._3-2022.pdf
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- Attached to
- Agency Administered OH|CTR032349
- Contract number
- CTR032349
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D & 2022-02D, governing the expenditure of public funds on offshore services and response to Russia's unjust war. The form is associated with a state contract and involves a contractor located in Rocky River, Ohio, with service locations in Toledo, Ohio. The document requires disclosure of business locations, service performance locations, and data storage locations to ensure compliance with specific executive orders prohibiting offshore services and purchases from Russian institutions.
The form does not specify the specific goods or services under contract, but it mandates that the contractor affirm understanding of prohibitions on offshore service performance, state data location, and purchasing from Russian entities. The contractor (signed by a Co-Owner named Jeff Hower) agrees to immediately notify the state of any changes in service or data location, with the state retaining the right to terminate the contract unless a waiver is obtained. The primary service location is listed as 1101 S. Detroit Ave. in Toledo, Ohio, with the contractor's principal business and data storage location at 3250 Nelson Park Dr. in Rocky River, Ohio. No subcontractors are indicated on this form.
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Other files
| File | Type | Posted |
|---|---|---|
| GSA_CTR032349_-_Ohio_Geese_Control.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: Toledo, Ohio 43614 | |
| 7vjIwGh8FrI6: 3250 Nelson Park Dr. | |
| 9CDPrbqPx9c9: | |
| Bu9SMGEElgkI: Rocky River, Ohio 44116 | |
| ceAJMaaBWx8J: Rocky River, Ohio 44116 | |
| DeEf8RMi1IsM: | |
| e0kKIuKR8cYN: | |
| ezvq1IC6uas0: | |
| i3aQCd8OJMYR: | |
| JzmIbNKnnZo7: | |
| rywWEDIypVE8: 3250 Nelson Park Dr | |
| teIBtP7gmx8U: | |
| Tq62FZqAAdcF: | |
| UuCZkmpSDw47: | |
| VkPBG475UyMR: | |
| Wqmw0RqVFXMR: | |
| y134HkjhDnIX: 1101 S. Detroit Ave. | |
| MVVuM0g3DMgL_QrDxZspIQjsR: Jeff Hower | |
| MVVuM0g3DMgL_JPzar1MhU68F: Co-Owner | |
| MVVuM0g3DMgL_PLLxiCDEsyAD: 2025-07-29 10:35:52 | |
| 2025-07-29T14:35:55+0000 | |
| Client IP: 76.210.15.9, Transaction ID: TbCCzXtuW-I0J9CIPfzpHoVIrk4= | |
| OneSpan | |
| E-SIGNED by Jeff Hower (jeff@ohiogeesecontrol.com), ID: b539f10b-ba2c-42f2-8dd2-c9895c5ab05d |
File details come from the government source that posted it. Updated .