1-Signed_Affirmation_and_Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically for the Ohio Department of Transportation (ODOT). The form is completed by Firelands Supply Co., located at 18 S. Norwalk Rd. in Norwalk, OH 44857. The document addresses restrictions on services performed outside the United States, particularly highlighting prohibitions on services by Russian companies or institutions under Executive Order 2019-12D.

The form details the contractor's principal business location, service performance location, and state data storage location, all of which are at the same address in Norwalk, OH. The contractor affirms compliance with regulations concerning public fund expenditures and agrees to disclose any changes in service locations before, during, and after contract execution. The document is part of a contractual agreement that incorporates Exhibit II and requires original signature, with the signatory being an authorized representative of Firelands Supply Co. who signed the document on 4-15-25.