1-Signed_Affirmation_and_Disclosure_Form_1.pdf
PDF 112 KB Posted
- Attached to
- Competitive Selection OH|DOT01526-3
- Contract number
- DOT01526-3
- Issued by
- Ohio
About this file
This document is an Affirmation and Disclosure Form related to an Ohio state contract, specifically issued by the Ohio Department of Transportation (ODOT). The form is completed by Utility Truck Equipment, located at 23893 US-23 South in Circleville, OH 43113. The document requires the contractor to affirm compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing services from Russian companies or institutions, and reinforces previous restrictions on offshore services.
The form confirms that all services and state data will be performed and located in Circleville, Ohio, with no services to be conducted outside the United States without a specific waiver. The contractor, represented by Jake Hill (Sales Manager), has signed the document on 6-09-2025, agreeing to immediately notify the state of any changes in service location and understanding that the state can terminate the contract if services are moved outside the United States without proper authorization. No specific details about the goods or services are provided in this disclosure document.
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Other files
| File | Type | Posted |
|---|---|---|
| 1-015-26_ODOT_Catalog.pdf | ||
| Signature__4___1___002_.pdf | ||
| 015-26_Bucket_Trucks.pdf | ||
| 1-015-26_Bucket_Trucks_Pricing_1.xlsx | XLSX spreadsheet |
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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:
(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:
(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:
(Address) (City, State, Zip)
Circleville, OH, 43113
23893 US-23 South
23893 US-23 South
23893 US-23 South Circleville, OH, 43113
Circleville, OH, 43113
File details come from the government source that posted it. Updated .