Standard Affirmation & Disclosure Form_fillable PDF Form.pdf
PDF 267 KB Posted
- Attached to
- Dillon Falls mowing and litter services State and local contract opportunity
- Solicitation number
- SRC0000030652
- Issued by
- Lake County, Ohio
About this file
The document is an Affirmation and Disclosure Form designed for state contract opportunities, requiring contractors to provide detailed information about their business locations and service performance sites. The form mandates that contractors and subcontractors perform all services within the United States and prohibit state data from being sent, accessed, or stored outside the country without a specific waiver from the state.
The form requires contractors to disclose their principal business location, locations where services will be performed, and specific sites where state data will be located, including details for both the primary contractor and any subcontractors. Contractors must affirm their ongoing obligation to immediately notify the state of any changes in service locations before, during, or after contract execution, with the understanding that the state retains the right to terminate the contract if services are moved outside the United States without proper authorization.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Dillon Falls Mowing and Litter Specifications FY26-27.doc | DOC document | |
| EXAMPLE Addendum to Bid Quote Base Template (example for procurement)_Rev. 2022 03 14.pdf | ||
| Standard Terms and Conditions.pdf | ||
| OPERS Independent Contractor Form_fillable PDF Form.pdf |
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Text version
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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