Affirmation_and_Disclosure_Form_-_Complete.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing restrictions on services from Russian companies or institutions pursuant to Executive Order 2022-02D. The form is completed by Southeastern Equipment Company, located at 10874 East Pike Rd in Cambridge, OH 43725, and is associated with the Ohio Department of Transportation (ODOT). The document requires the contractor to disclose details about business locations, service performance sites, and potential subcontractors, while affirming compliance with state regulations regarding Russian service providers.

The form indicates that no subcontractors are currently identified, and all service locations are marked as "N/A" (not applicable). The contractor agrees to immediate notification of any changes in service locations or contract conditions, and acknowledges the state's right to terminate the contract if services are performed outside the United States. The document is signed by the Regional Sales Manager on September 24, 2024, and is part of a broader executive order prohibiting state agencies from purchasing services from Russian companies or institutions, with ODOT reserving the right to recover funds paid for any such services.