Standard_Affirmation___Disclosure_Form_fillable_PDF_Form__11___1_ (1).pdf

293 KB Posted

Attached to
2025 Old Woman Creek Window Replacement
Solicitation number
SRC0000028633
Issued by
Erie County, Ohio

About this file

Written by GovTribe AI ·

The document is a Standard Affirmation and Disclosure Form related to state contract requirements for service performance and data location. The form mandates that contractors and their subcontractors perform all contracted services within the United States and ensure that state data remains domestically located, with no services or data processing occurring outside the country without explicit state-approved waivers. Contractors are required to disclose their principal business locations, specific service performance locations, and the precise sites where state data will be stored or managed.

The form emphasizes continuous disclosure obligations, requiring contractors to immediately notify the state of any changes in service or data location before, during, and after contract execution. The state retains the right to terminate the contract if location requirements are not met without obtaining a signed waiver. The document serves as a critical compliance mechanism to ensure geographic constraints on service delivery and data management, with potential contract termination as a consequence for non-compliance. Contractors must sign and authorize the form, acknowledging their understanding and agreement to these stringent location and disclosure requirements.

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Version 2/20 Page 1 of 2

AFFIRMATION AND DISCLOSURE FORM

By the signature affixed hereto, the Contractor affirms and understands that if awarded a contract, both the Contractor and any of its subcontractors shall perform no services requested under this Contract outside of the United States, nor allow State data to be sent, taken, accessed, tested, maintained, backed-up, stored or made available remotely (located) outside of the United States unless a duly signed waiver from the State has been attained.

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

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 where services will be performed by Contractor:

(Address) (City, State, Zip)

Name/Location where services will be performed by subcontractor(s):

Version 2/20 Page 2 of 2

3. Location where state data will be located, by Contractor:

(Address) (Address, City, State, Zip)

Name/Location(s) where state data will be located by subcontractor(s):

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 its 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 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 State and is incorporated therein.

By: __________________________________ Contractor

Print Name: ___________________________

Title: __________________________________

Date: __________________________________

Address:
City State Zip:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Name_3:
Name_4:
Address City State Zip_3:
Address City State Zip_4:
Address_3:
Address City State Zip_5:
Name_5:
Name_6:
Name_7:
Name_8:
Name_9:
Address City State Zip_6:
Address City State Zip_7:
Address City State Zip_8:
Address City State Zip_9:
Address City State Zip_10:
Text3:
Printed Name:
Signature:
Date:

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