Standard_Affirmation_and_Disclosures-Ohio_-_signed.pdf
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- Attached to
- Agency Administered OH|CTR028629
- Contract number
- CTR028629
- Issued by
- Ohio
About this file
This document is a Standard Affirmation and Disclosure Form for Executive Orders 2019-12D & 2022-02D, specifically addressing offshore services and response to Russia's actions. The form is completed by Station MD, located at 515 Valley St. #203 in Maplewood, NJ 07040, and pertains to services potentially involving the state of Ohio. The document requires the contractor to affirm compliance with prohibitions on offshore services, locating state data offshore, and purchasing from Russian institutions or companies.
The contractor indicates that services and state data will be located within AWS US East and West data centers in Ohio and Oregon, USA. The form emphasizes the contractor's obligation to disclose any changes in service locations before, during, and after contract execution, with the state retaining the right to immediately terminate the contract unless a signed waiver is obtained. The document was electronically signed by Matthew Kaufman on June 27, 2025, and appears to be part of a standard compliance process for state government contracting.
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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):
515 Valley St. #203 Maplewood, NJ 07040
515 Valley St. #203 Maplewood, NJ 07040
AWS US East and West Ohio and Oregon USA
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: ___________________________________
Signature:
Email:
Matthew Kaufman (Jun 27, 2025 07:27 EDT) matthew.kaufman@stationmd.com
Standard Affirmation and Disclosures-Ohio Final Audit Report 2025-06-27
Created: 2025-06-26
By: Emily Martinez (emily.martinez@stationmd.com)
Status: Signed
Transaction ID: CBJCHBCAABAAzcGMghRJkJSxxC0I5KDDX7mhu32Cr0kf
"Standard Affirmation and Disclosures-Ohio" History Document created by Emily Martinez (emily.martinez@stationmd.com)
2025-06-26 - 4:55:39 PM GMT
Document emailed to Matthew Kaufman (matthew.kaufman@stationmd.com) for signature
2025-06-26 - 4:57:46 PM GMT
Email viewed by Matthew Kaufman (matthew.kaufman@stationmd.com)
2025-06-27 - 11:27:05 AM GMT
Document e-signed by Matthew Kaufman (matthew.kaufman@stationmd.com) Signature Date: 2025-06-27 - 11:27:17 AM GMT - Time Source: server
Agreement completed.
2025-06-27 - 11:27:17 AM GMT
| 2025-06-27T11:27:19+0000 | |
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