Affirmation_and_Disclosure_Form__10_.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing requirements under Executive Order 2022-02D. The form is completed by Southern Fasteners & Supply, with a principal business location at 2421 W. Clemmonsville Rd, Winston Salem, NC 27127. The contractor affirms compliance with restrictions on services performed by Russian companies or institutions, in line with state and federal guidelines.

The form specifies that services will be performed at 300 315th Street in Parkersburg, WV 26101, with all state data to be located at the company's primary address in Winston Salem, NC. There are no subcontractors listed, and the document emphasizes the contractor's commitment to not performing any services in Russia and adhering to Executive Order 2022-02D. The form was signed by Kevin Frazier, Program Manager, on 11/11/2025, affirming the company's understanding and agreement to the contract's terms and conditions.