Affirmation_and_Disclosure_Form_Crossroads_Asphalt_Recycling.pdf

This document is an Affirmation and Disclosure Form related to Executive Order 2022-02D, specifically addressing restrictions on state contracts involving Russian companies or services. The form is completed by Crossroads Asphalt Recycling, Inc., with its principal place of business located at 13421 Hawke Road in Columbia Station, Ohio 44028. The document is part of a contract compliance process that prohibits state agencies from purchasing offshore services from Russia and requires contractors to affirm their non-involvement with Russian entities.

The form confirms that all services under this contract will be performed at the company's address in Columbia Station, Ohio, with no subcontractors listed. The contractor agrees to immediately notify the state of any changes in service locations and understands that failure to provide complete information may result in contract non-award. The document was signed by the company's president on 2/25/25, affirming compliance with the executive order's requirements regarding the performance and location of contract services, and explicitly stating that no services will be performed in Russia.