1-Affirm___Disc_Form-SRC33929.pdf
PDF 95 KB Posted
- Attached to
- Competitive Selection OH|DOT13526-1
- Contract number
- DOT13526-1
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form from Red Vest Supply, LLC, a contractor for the Ohio Department of Transportation (ODOT) 12th District. The form affirms the contractor's understanding of Executive Orders regarding offshore services, state data location, and purchasing restrictions, specifically prohibiting interactions with Russian institutions or companies.
The form details the contractor's primary business location at 1656 Lynnbrook Ct. in Orient, Ohio, with Michael Lackey listed as the President/Owner. Services will be performed at the ODOT 12 District location, and the document requires disclosure of any potential changes in service locations or data storage. The form was signed by Michael Lackey on 9/30/2025, with the contractor agreeing to immediately notify the state of any location shifts and acknowledging that the state can terminate the contract if services are performed outside the United States without a proper waiver.
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Text version
Version 5/24 Page 1 of 2
AFFIRMATION AND DISCLOSURE FORM
Contractor affirms that Contractor has read and understands the applicable Executive Orders regarding the prohibitions of performance of offshore services, locating State data offshore in any way, or purchasing from Russian institutions or companies.
The Contractor shall provide the name(s) and location(s) where all services under this Contract will be performed and where State data will be located in the spaces provided below or by attachment. If the Contractor will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.
Contractor Name: ___________________________ Contract Number:
1. Principal business location of Contractor:
(Address) (City, State, Zip)
Name(s)/Principal business location(s) of subcontractor(s):
(Name) (Address, City, State, Zip)
2. Location(s) where services will be performed by Contractor:
Name(s)/Location(s) where services will be performed by subcontractor(s):
Red Vest Supply, LLC 740-357-7375
1656 Lynnbrook Ct. Orient, OH 43146
Michael Lackey 1656 Lynnbrook Ct. Orient, OH 43146
ODOT 12 District
Version 5/24 Page 2 of 2
3. Location(s) where any State data associated with any of the services Contractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:
Name(s)/Location(s) where any State data associated with any of the services any subcontractor is providing, or seeks to provide, will be accessed, tested, maintained, backed-up, or stored:
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 to notify the State immediately of any such change or shift in location of its services. The State has the right to terminate the contract if any services are performed or State data is located outside of the United States unless a duly signed waiver from the State has been attained.
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: __________________________________ Authorized Contractor Signature
Print Name: ___________________________
Title: __________________________________
Date: __________________________________
Michael Lackey
President/ Owner
9/30/2025
File details come from the government source that posted it. Updated .