Standard Affirmation & Disclosure Form_fillable PDF Form.pdf

267 KB Posted

Attached to
Beaver Wildlife Area Sunflower Field
Solicitation number
SRC0000017372
Issued by
Marion County, Ohio

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Written by GovTribe AI ·

This document is an Affirmation and Disclosure Form to be completed by contractors and subcontractors providing services to the State of Ohio. 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 locations. The contractor affirms that they will not perform any services or store any data outside of the United States unless a waiver is obtained from the State. The contractor also agrees to notify the State of any changes or shifts in the location of their services during the contract term.

The related state and local contract opportunity is for the bid to plant a 5-acre sunflower field at the Beaver Wildlife Area in Marion County, Ohio. The contract is being issued by the State of Ohio, and the jurisdiction is Marion County.

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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:
Name:
Address City State Zip:
Name_2:
Address City State Zip_2:
Address_2:
City State Zip_2:
Name_3:
Name_4:
Address City State Zip_3:
Address City State Zip_4:
Address_3:
Address City State Zip_5:
Name_5:
Name_6:
Name_7:
Name_8:
Name_9:
Address City State Zip_6:
Address City State Zip_7:
Address City State Zip_8:
Address City State Zip_9:
Address City State Zip_10:

File details come from the government source that posted it. Updated .