AFFIRMATION_AND_DISCLOSURE_FORM__5_.pdf

This document is an Affirmation and Disclosure Form executed by Phillips Oil Company of Central Ohio Inc., addressing compliance with Executive Order 2022-020D regarding prohibitions on services from Russian companies. The form is associated with the Ohio Department of Transportation (ODOT) and involves a contract where the contractor affirms its principal business location is at 1877 McKinley Ave, Columbus, Ohio 43222.

The form outlines the contractor's commitment to not perform any services under this contract in Russia and to complete Exhibit II, which is a Contractor/Subcontractor Affirmation and Disclosure Form. The document emphasizes compliance with state regulations prohibiting the purchase of services from Russian companies or institutions, as outlined in Executive Order 2019-12D. The contractor has confirmed that all services will be performed at the same address (1877 McKinley Ave, Columbus, Ohio 43222) and that no subcontractors are currently involved in the contract. The form was signed by the company president on February 13, 2025, affirming these commitments.