AFFIRMATION_AND_DISCLOSURE_FORM__2_.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing compliance with Executive Order 2022-02D. The form is completed by HL Gray Enterprises Inc., located at 1390 Tall Timbers Ct in Miamisburg, OH 45342, for services to be performed in District 7 & 8. The document requires the contractor to affirm understanding of restrictions on performing services outside the United States and specifically addresses prohibitions related to Russian companies or institutions.

The form indicates no subcontractors are involved, and the contractor's primary business location and state data location are the same address in Miamisburg, Ohio. The document emphasizes compliance with Executive Order 2019-12D, which prohibits state agencies from purchasing offshore services from Russia. The contractor agrees to complete Exhibit II and acknowledges that failure to provide required information could result in the contract being withheld. The form is signed by the company's president on 9/3/2025, affirming the contractor's commitment to these terms and conditions.