Standard_Affirmation___Disclosure_Form_fillable_PDF_Form.pdf
PDF 267 KB Posted
- Attached to
- Asphalt Repair at Van Buren State Park
- Solicitation number
- SRC0000017839
- Issued by
- Hancock County, Ohio
About this file
This document is a Standard Affirmation and Disclosure Form for a state and local contract opportunity in Ohio. The contract is for asphalt repair work at Van Buren State Park in Hancock County, Ohio. The scope of work includes patching potholes and rough asphalt areas throughout the park. The contract will be awarded to the lowest responsive and responsible bidder, with the contract award determination made by multiplying the unit cost by the estimated usage. A site visit is encouraged prior to submitting a bid, and failure to conduct a site visit will not be sufficient reason to be released from the contract. The contract term is through June 30, 20XX.
The pricing terms require the bidder to provide a unit cost, with the low lot total determining the award. There are no set asides mentioned, and the current incumbent is not specified. The funding source is the State of Ohio, with invoices to be submitted directly to Ohio Shared Services. Interested parties must include the provided purchase order number, origin number, and other required information on invoices to facilitate processing.
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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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