Standard Affirmation Disclosure Form fillable PDF Form.pdf

267 KB Posted

Attached to
PWC SW M Lake Loramie Barnes Submersible Grinder Pump
Solicitation number
SRC0000018449
Issued by
Auglaize County, Ohio

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Written by GovTribe AI ·

The document is an Affirmation and Disclosure Form that must be completed by a contractor awarded a contract by the State. The form requires the contractor to affirm that all services will be performed within the United States and that no state data will be located or accessed outside of the United States without a signed waiver. The contractor must provide the principal location of their business as well as the location(s) where services will be performed and where state data will be located, including any subcontractor information. The contractor acknowledges a duty to disclose any changes in service location before, during, and after contract execution, with the State having the right to terminate the contract if services are performed outside the U.S. without a waiver.

The related state and local contract opportunity is for the purchase of two Barnes submersible grinder pumps and associated equipment for a lift station located at Lake Loramie State Park in Auglaize County, Ohio. The project is urgent due to a pump failure, with the need to replace the pump before the high-demand camping season. The specifications include the pump model, size, voltage, and cord length, as well as a vertical pump discharge and capacitor kit. The completion and delivery date for the equipment is prior to June 2024.

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PWC SW RFQ Lake Loramie Submersible Pump.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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