101G-26_-_Affirmation_and_Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically for Unique Paving Materials Corp., located at 3993 E 93rd Street in Cleveland, Ohio 44105. The form is associated with the Ohio Department of Transportation (ODOT) and addresses compliance with Executive Order 2022-02D regarding services performed in or connected to Russia, with specific attention to restrictions on state agencies' purchases and service requirements.

The contractor has indicated that services will be performed at their primary business location in Cleveland, Ohio, with potential service locations across the state of Ohio. No subcontractors are listed, and the company affirms it will not be performing services in Russia. The form requires disclosure of business locations, service performance locations, and state data storage locations, with the company using its primary address for all three categories. The document was signed by the company's treasurer on 2/12/25, affirming compliance with state contract requirements and agreeing to notify the state of any changes in service locations or contract conditions.