1-Affirmation_and_Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing requirements under Executive Order 2022-02D. The form is completed by Kimco USA Inc., located at 118 E. Trefz Dr. in Marshall, IL 62441. The document pertains to restrictions on purchasing services from Russian companies or institutions, as mandated by Ohio's Executive Order 2019-12D, and involves potential contract obligations with a state agency (likely ODOT - Ohio Department of Transportation).

The form indicates that Kimco USA Inc. will perform all contract services at its primary business location in Marshall, IL, with no subcontractors involved. The company affirms it will not use Russian companies or institutions in contract performance and agrees to immediately disclose any changes in service locations or subcontractor arrangements. The document is signed by the company's Vice President, Blake D. Coffey, with an execution date of 9/16/2025, and serves as a compliance document ensuring the contractor's adherence to state procurement restrictions and data handling regulations.