1-Affirmation_and_Disclosure_sig.pdf
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- Attached to
- Competitive Selection OH|DOT01326-3
- Contract number
- DOT01326-3
- Issued by
- Ohio
About this file
The document is an Affirmation and Disclosure Form completed by Kueper North America, LLC, related to a state contract with the Ohio Department of Transportation (ODOT). The form affirms compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing services from Russian companies or institutions. The contractor, located at 171 Church St., Suite 300 in Charleston, SC 29401, certifies that all services will be performed within the United States and that no state data will be stored or accessed outside the United States without a specific waiver.
The form does not provide specific details about the goods or services under contract, pricing terms, or contract duration. However, it emphasizes the contractor's commitment to performing all work within the United States and immediately disclosing any potential changes in service locations. The document includes provisions that allow ODOT to terminate the contract if the contractor attempts to perform services outside the United States or fails to notify the state of any location changes. The form was signed by Patricia Schuster, Vice President of Kueper North America, LLC, on 5/27/2025, indicating the company's understanding and agreement to these terms.
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Text version
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, not 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 will not be using subcontractors, indicate “Not Applicable” in the appropriate spaces.
EXPENDITURE OF PUBLIC FUNDS ON SERVICES PERFORMED BY RUSSIAN COMPANIES OR INSTITUTIONS.
The Contractor affirms to have read and understands Executive Order 2022-02D and shall abide by those requirements in the performance of this Contract. Pursuant to this Executive Order, all state agencies are prohibited from the purchase of services from Russian companies or institutions. This prohibition is in addition to and expands upon Executive Order 2019-12D which generally precludes the purchase of offshore services by the State of Ohio. Notwithstanding any other terms of this Contract, ODOT reserves the right to recover any funds paid for services the Contractor performs in Russia in violation of this Executive Order. ODOT does not waive any other rights and remedies provided to ODOT in this Contract.
The Contractor agrees to complete the attached Exhibit II, Contractor/Subcontractor Affirmation and Disclosure Form, to abide with Executive Order 2022-02D, which is incorporated and becomes a part of this Contract, affirming no services of the Contractor or its subcontractors under this Contract will be performed in Russia.
1. Principal location of business of Contractor:
___171 Church St., Suite 300_____________ __Charleston, SC 29401_____________ (Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
___171 Church St., Suite 300______________ ___ Charleston, SC 29401_____________ (Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
3. Location where state data will be located, by Contractor:
___171 Church St., Suite 300______________ ___ Charleston, SC 29401___________ (Address) (City, State, Zip)
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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.
(AN ORIGINAL SIGNATURE IS REQUIRED)
Company Name: _Kueper North America, LLC_____
Signature: __________________________________
Print Name: ____Patricia Schuster_______________
Title: ____Vice President_______________________
Date: ___5/27/2025___________________________
File details come from the government source that posted it. Updated .