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Get OH Standard Affirmation and Disclosure Form 2011-2021

VFinal 09/11 STANDARD AFFIRMATION AND DISCLOSURE FORM EXECUTIVE ORDER 2011-12K Governing the Expenditure of Public Funds on Offshore Services All of the following provisions must be included in all invitations to bid requests for proposals state term schedules multiple award contracts requests for quotations informal quotations and statements of work. This information is to be submitted as part of the response to any of the procurement methods listed* By the signature affixed hereto the Contractor affirms understands and will abide by the requirements of Executive Order 2011-12K. 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. The Contractor shall provide all the name s and location s where services under this Contract will be performed in the spaces provided below or by attachment. Failure to provide this information may subject the Contractor to sanctions. If the Contractor will not be using subcontractors indicate Not Applicable in the appropriate spaces. 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 Name/Location where services will be performed by subcontractor s Page 1 of 2 Contractor 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 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 Print Name Title Date. This information is to be submitted as part of the response to any of the procurement methods listed* By the signature affixed hereto the Contractor affirms understands and will abide by the requirements of Executive Order 2011-12K. 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. 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. The Contractor shall provide all the name s and location s where services under this Contract will be performed in the spaces provided below or by attachment. The Contractor shall provide all the name s and location s where services under this Contract will be performed in the spaces provided below or by attachment. Failure to provide this information may subject the Contractor to sanctions. If the Contractor will not be using subcontractors indicate Not Applicable in the appropriate spaces. .

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