101G-26_Affirmation___Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically prepared for Walls Asphalt Mfg. Inc. The form is tied to Executive Order 2022-02D and pertains to restrictions on expenditure of public funds for services performed by Russian companies or institutions. The document is associated with the Ohio Department of Transportation (ODOT) and requires contractors to affirm compliance with specific guidelines regarding service locations, data handling, and potential contract termination conditions.

The form indicates that the contractor (Walls Asphalt Mfg. Inc.) has no services to be performed in Russia, with "Not Applicable" marked for principal business location, service performance location, and state data location. The document emphasizes that neither the contractor nor its subcontractors will perform services in Russia, and the company is bound by the requirements of the Executive Order 2019-12D, which prohibits purchasing services from Russian companies or institutions. The form is signed by Chris Dittus, Vice President of Walls Asphalt Mfg. Inc., with an execution date of 2/11/2025, signifying the company's commitment to these contractual and governmental requirements.