AFFIRMATION_AND_DISCLOSURE_FORM__4_.pdf

The document is an Affirmation and Disclosure Form related to a state contract, completed by JEM Industrial Maint. Corp. located at 6205 McClain Rd. in Wapakoneta, OH 45895. The form addresses compliance with Executive Order 2022-02D, specifically focusing on restrictions for services performed by Russian companies or institutions, and requires the contractor to affirm their commitment to not engage in services within Russia.

The form details the contractor's primary business location and service performance location as the same address in Wapakoneta, Ohio. No specific goods or services are explicitly outlined in the document, but the contractor agrees to abide by Ohio state regulations regarding offshore services and acknowledges the state's right to terminate the contract if there are any undisclosed changes in service location or performance. The document was signed by the company's President on 1-15-2025, certifying compliance with the stated executive order and contractual requirements.