Standard Affirmation & Disclosure Form_fillable PDF Form.pdf

267 KB Posted

Attached to
Wright Davis Scenic River Land - Gravel Parking Lot Installation
Solicitation number
SRC0000017926
Issued by
Ashtabula County, Ohio

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Written by GovTribe AI ·

This document is a Standard Affirmation and Disclosure Form that is part of a state and local contract opportunity from the Ohio Department of Natural Resources, Division of Natural Areas and Preserves, Scenic Rivers Program. The contract opportunity is for the installation of a gravel parking lot at the Wright Davis Scenic River Land located in Harpersfield Township, Ashtabula County, Ohio. The project must be completed by June 25, 2024, and the contract will be awarded to the lowest responsive and responsible bidder. The form requires the contractor to disclose the principal location of their business, the locations where services will be performed, and the locations where state data will be stored, including any subcontractor information.

The contract opportunity is for a fixed-price contract, and the award will be based on the low lot total calculated by multiplying the unit cost by the estimated usage. Failure to bid on all items may result in the bidder being deemed non-responsive. There are no set-asides, incumbents, or specific funding requirements mentioned in the document.

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Other files

File Type Posted
OPERS Independent Contractor Form_fillable PDF Form.pdf PDF
Wright-Davis Parking Lot RFQ 03262024 amended 04122024.pdf PDF
Standard_T_C_04-10-23.pdf PDF
Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys.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: __________________________________

Address:
City State Zip:
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Name_5:
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