Affirmation_and_Disclosure-IRS-25__1_.pdf

This document is an Affirmation and Disclosure Form for Impact Recovery Systems, Inc., a contractor based in San Antonio, Texas, pertaining to a contract with the Ohio Department of Transportation (ODOT). The form addresses compliance with Executive Order 2022-02D, which prohibits the purchase of services from Russian companies or institutions, and requires detailed disclosure of the contractor's business locations and service performance sites.

The form indicates that Impact Recovery Systems, Inc. will perform services at 4955 Stout Dr in San Antonio, TX 78219, with no subcontractors involved. The contractor affirms that no services under this contract will be performed in Russia, and agrees to complete the attached Exhibit II, which incorporates the Contractor/Subcontractor Affirmation and Disclosure Form. The document is signed by the company president on 9/23/2024, acknowledging the terms of the contract and the restrictions on service delivery related to Russian entities.