Standard Affirmation & Disclosure Form_fillable PDF Form.pdf

267 KB Posted

Attached to
PWC Guilford Park Office Low Pile Carpet
Solicitation number
SRC0000016165
Issued by
Clinton County, Ohio

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Written by GovTribe AI ·

The document is a Standard Affirmation & Disclosure Form that is required for contractors providing services to the State of Ohio. The form affirms that the contractor and any subcontractors will perform all services and store all data within the United States, unless a waiver is obtained. The contractor must disclose the principal locations of their business, the locations where services will be performed, and the locations where state data will be stored. The contractor also acknowledges a duty to disclose any changes in the location of services during the contract term, and that the State has the right to terminate the contract if services are performed outside the United States without a waiver.

The related state and local contract opportunity is for the procurement of new commercial low pile carpet, including removal of existing carpet, for the State of Ohio administrative office located in Columbiana County. The contract is being issued by Guilford Lake State Park.

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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:

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