Standard_Affirmation___Disclosure_Form_fillable_PDF_Form.pdf

267 KB Posted

Attached to
Refuse Service for Indian Lake State Park Logan County
Solicitation number
SRC0000015738
Issued by
Logan County, Ohio

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This document is an Affirmation and Disclosure Form required for a state and local contract opportunity related to refuse service for Indian Lake State Park in Logan County, Ohio. The contract requires the successful bidder to perform all services within the United States and disclose any change in the location of services during the contract term. The initial contract term is 16 months from March 2024 through June 2025, with an optional 2-year renewal through June 2027. The scope of work includes providing refuse pickup services, with all monthly prices to include any applicable fees. Bidders must complete an accompanying Excel spreadsheet and submit it with their bid. A site visit prior to bid submission is encouraged but not required. The contract will be awarded to the lowest responsive and responsible bidder.

The contract opportunity includes veteran-friendly business enterprise (VBE) and Buy Ohio/Buy American preferences, which may allow bids from certified VBE firms or those containing Ohio/American products to exceed the lowest bid by up to 5% or 6% and still be eligible for award. Invoices must be submitted directly to Ohio Shared Services, and the awarded supplier will be required to sign an Addendum to Bid Quote or Personal Services Agreement.

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Other files

File Type Posted
RFP_Refuse Service_Indian Lake in Logan County.xlsx XLSX spreadsheet
RFP_Refuse Service_Indian Lake in Logan County.pdf PDF
Standard_T_C_04-10-23.pdf PDF
Services Agreement (Non-Federal Funds) Base Template_Rev. 2023 04 11.pdf PDF

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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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