Affirmation_and_Disclosure__1_.pdf
PDF 266 KB Posted
- Attached to
- Competitive Selection OH|DOT80026-4
- Contract number
- DOT80026-4
- Issued by
- Ohio
About this file
The document is an Affirmation and Disclosure Form for the State of Ohio, specifically for the Ohio Department of Transportation (ODOT), involving Mike Maurice Group, LLC as the contractor and Brandi Cooper as a subcontractor. The form is designed to ensure compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing services from Russian companies or institutions, and reinforces previous restrictions on offshore services.
The form details the contractor's principal business location at 470 W Broad St #1125 in Columbus, Ohio, with services to be performed at the same address. The contractor, Mike Maurice Group, LLC, and its subcontractor, Brandi Cooper, affirm that no services will be performed outside the United States, and state data will be maintained within the United States. The document requires the contractor to immediately disclose any changes in service locations and grants ODOT the right to terminate the contract if services are moved outside the United States without a signed waiver.
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Other files
| File | Type | Posted |
|---|---|---|
| Signature.pdf | ||
| _800-26_Aggregate__800-26_Pricing_1.xlsx | XLSX spreadsheet | |
| 800-26.pdf | ||
| _800-26_Aggregate__800-26_Pricing_2.xlsx | XLSX spreadsheet |
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Text version
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:
(Address) (City, State, Zip)
Name/Principal location of business of subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
2. Location where services will be performed by Contractor:
(Address) (City, State, Zip)
Name/Location where services will be performed by subcontractor(s):
(Name) (Address, City, State, Zip)
3. Location where state data will be located, by Contractor:
(Address) (City, State, Zip)
Brandi Cooper 470 W Broad St #1125
Brandi Cooper Columbus, Oh 43215
Brandi Cooper
Brandi Cooper 470 W Broad St #1125
Brandi Cooper 286 Marjoram Dr Columbus, Oh 43230
Brandi Cooper Brandi Cooper
Brandi Cooper Columbus, Oh 43215
Brandi Cooper Brandi Cooper
470 W Broadf St Columbus, Oh 43215
Name/Location(s) where state data will be located by subcontractor(s):
(Name) (Address, City, State, Zip)
(Name) (Address, City, State, Zip)
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: _____________________________
Signature: __________________________________
Print Name: ________________________________
Title: ______________________________________
Date: ______________________________________
470 W Broad St Columbus, Oh 43215
Brandi Cooper Brandi Cooper
Brandi Cooper 2/27/2025
Brandi Cooper President
Brandi Cooper Brandi Cooper
Mike Maurice Group, LLC
File details come from the government source that posted it. Updated .