12-13_Completed_Affirmation_and_Disclosure__10_.pdf

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: 5388 Dawson Rd, Houston Oh 45333

(Address) City, State, Zip)

Name/Principal location of business of subcontractor(s):

___Ben Koberstein WI ___________ _________________________________

(Name) Address, City, State, Zip)

___Shawn Sarsfield IW

2. Location where services will be performed by Contractor: ODOT Site Location

Name/Location where services will be performed by subcontractor ODOT Site Location

3. Location where state data will be located, by Contractor:

__5388 Dawson, RD Houston Ohio 45333_________________________________

Name/Location(s) where state data will be located b y subcontractor(s):

_Qualified Crane Training & Consulting LLC___ Dawson RD, Houston Ohio 45333

Contractor also affirms, understands and agrees that Contractor and its subcontractors are under a duty to disclose to the State any change or shift in location of services performed by Contractor or its subcontractors before, during and after execution of any contract with the State. Contractor agrees it shall so notify the State immediately of any such change or shift in location of its services. The State has the right to immediately terminate the contract, unless a duly signed waiver from the State has been attained by the Contractor to perform the services outside the United States.

On behalf of the Contractor, I acknowledge that I am duly authorized to execute this Affirmation and Disclosure Form and have read and understand that this form is a part of any Contract that Contractor may enter into with the State and is incorporated therein.

(AN ORIGINAL SIGNATURE IS REQUIRED)

Company Name: ____ Qualified Crane Training & Consulting LLC _________________________

Signature: __________________________________

Print Name: ________________________________

Title: ______________________________________

Date: ______________________________________

Jennifer Street Typewriter Jennifer Street

Jennifer Street Typewriter Office Manager

Jennifer Street Typewriter 12/13/2024