Standard_Affirmation___Disclosure_Form_-_Adkins_Fence_Company.pdf
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- Attached to
- Agency Administered OH|CTR032286
- Contract number
- CTR032286
- Issued by
- Ohio
About this file
This is a Standard Affirmation and Disclosure Form related to Executive Orders 2019-12D and 2022-02D, governing the expenditure of public funds on offshore services and responding to Russia's actions. The document is completed by a contractor located in Fremont, Ohio, and appears to be part of a state contract submission requiring disclosure of business and service locations.
The contractor, JR Adkins (signed by a Manager), affirms that all services will be performed domestically, specifically at 600 North River Rd in Tiffin, Ohio, with company principal business located at 2226 W. Garrison in Fremont, Ohio. The form requires full transparency about service and data locations, with the contractor agreeing to immediately notify the state of any potential changes in service locations. No subcontractors are listed, and the contractor confirms all operations will be conducted within the United States, in compliance with the specified executive orders prohibiting offshore services and purchases from Russian institutions.
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| File | Type | Posted |
|---|---|---|
| CTR032286_-_Adkins_Fence_Company_TDC_Executed_Agreement.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)
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: 2226 w. Garrison |
| City State Zip: Fremont, Ohio 43420 |
| Name: |
| Address City State Zip: |
| Name_2: |
| Address City State Zip_2: |
| Address_2: 600 North River Rd |
| City State Zip_2: Tiffin, Ohio 44883 |
| Name_3: |
| Address City State Zip_3: |
| Name_4: |
| Address City State Zip_4: |
| Address_3: 2226 W. Garrison |
| City State Zip_3: Fremont, Ohio 43420 |
| Name_5: |
| Address City State Zip_5: |
| Name_6: |
| Address City State Zip_6: |
| By: JR Adkins |
| Print Name: JR Adkins |
| Title: Manager |
| Date: 7/18/2025 |
File details come from the government source that posted it. Updated .