1-Affirmation___Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form for a state contract, specifically related to Ohio Department of Transportation (ODOT) requirements. The form is completed by Site Safe, LLC, located in Litchfield, KY, with its primary business address at 200 Judge Kenneth H. Gott Dr. The document pertains to compliance with Executive Order 2022-020, which addresses restrictions on services performed by Russian companies or institutions.

The contract services will be performed at 1500 Obetz Rd. in Columbus, OH, which is also the location where state data will be located. The form emphasizes that the contractor affirms no services will be performed in Russia and agrees to abide by the prohibition on purchasing services from Russian companies or institutions, as outlined in the Executive Order. The document serves as a mandatory disclosure of the contractor's business location, service performance location, and commitment to not engage with Russian entities in the context of the state contract.