101G-26_Affirmation___Disclosure_Form__4_.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically involving the Ohio Department of Transportation (ODOT). The form is executed by Valley Asphalt Corporation, with the Vice President Chris Dittus signing on behalf of the company. The document is designed to comply with Executive Order 2022-02D and addresses requirements for services performed by or involving Russian companies or institutions, with particular emphasis on prohibitions and restrictions stemming from the ongoing geopolitical context.

The form indicates that all sections are marked "Not Applicable", suggesting that Valley Asphalt Corporation will not be utilizing Russian companies, subcontractors, or performing services in Russia for this contract. The document requires the contractor to affirm compliance with restrictions on purchasing services from Russian entities, in line with the State of Ohio's regulations. While specific contract details are not elaborated in this form, it serves as a critical compliance document ensuring that the contractor understands and agrees to abide by state-mandated restrictions on international service provisions. The form is dated 2/11/2025, implying it is part of a future contract or procurement process.