19-25_AFFIRMATION_AND_DISCLOSURE.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 completed by Peterson Holding Safety, Inc., located in Columbus, OH, and pertains to compliance with Executive Order 2022-02D regarding restrictions on expenditures of public funds on services performed by Russian companies or institutions. The contractor affirms that no services under this contract will be performed in Russia and agrees to abide by the specified executive order.

The document indicates that the contract location and services will be performed at P.O. Box 1510, 950 Dublin Rd. in Columbus, OH 43216. No subcontractors are listed, with "N/A" entered in those sections. The form emphasizes the contractor's commitment to not using Russian companies or institutions in contract performance, with ODOT reserving the right to recover funds paid for any services performed in Russia in violation of the executive order. The form was signed by the company president on August 19, 2024, and serves as a critical compliance document for state contracting requirements.