2025-06-27_11-12.pdf

This document is an Affirmation and Disclosure Form related to a state contract, completed by Jeffrey R. Chambers, a Member/Owner of a business located at 16191 Hunters Run in Marysville, Ohio 43040. The form requires the contractor to disclose information about business locations, service performance locations, and state data storage locations, while affirming compliance with Executive Orders regarding offshore services and restrictions on doing business with Russian institutions.

The contractor will perform services at 3791 State Route 63 in Lebanon, Ohio 45036, with state data to be located at the Marysville, Ohio address. No subcontractors are planned for this contract (marked as "N/A" on the form). The document indicates the contractor understands the requirement to disclose any changes in service locations or subcontractors to the state, and has the right to perform services outside the United States unless a signed waiver is obtained. The form is dated for execution on 6-27-2025, suggesting a future contract or renewal period.