Standard Affirmation & Disclosure Form_fillable PDF Form.pdf
PDF 267 KB Posted
- Solicitation number
- SRC0000028299
- Issued by
- Putnam County, Ohio
About this file
The document is a Standard Affirmation and Disclosure Form from the Ohio Department of Natural Resources (ODNR) related to the FY25 Magee Marsh Wildlife Area Wetland Embankment Stabilization project. The form requires contractors to affirm that all services will be performed within the United States and to disclose the locations of their principal business, service performance, and data storage. Mandatory site visits are scheduled for March 6th and 13th, 2025, at 12:00 PM, with contractors required to contact Patrick Baranowski to schedule an appointment. The project involves stabilizing wetland embankments across four sites totaling 4,875 linear feet, including mowing vegetation, repairing damage, and placing specific types of stone to armor slopes.
The contract will be awarded to the lowest responsive and responsible bidder, with preference calculations including 5% for first preference and 2% each for second and third preferences for Buy American, Buy Ohio, and Veteran-Friendly Business categories. Contractors must be registered with the Ohio Secretary of State and comply with MBE/EDGE vendor participation requirements. The project mandates specific insurance coverages, including commercial general liability of $1M per occurrence and automobile liability of $1M per accident. All work must be completed by June 30, 2025, with bidding conducted on a per linear foot basis and the final contracted length determined by the available project budget. Contractors must adhere to prevailing wage rates and all federal, state, and local regulations.
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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: __________________________________
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