Affirmation_and_Disclosure_signed.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing requirements under Executive Order 2022-02D. The form is completed by Pickett Concrete, located in Chesapeake, OH, and pertains to contractual obligations involving state agencies and potential service locations. The document emphasizes compliance with restrictions on performing services in Russia and requires disclosure of business locations and service performance sites.

The contract involves service locations at 300 Marion Pike and 441 Rockwood Avenue in Coal Grove and Chesapeake, Ohio, respectively. The form outlines the contractor's commitment to not use subcontractors for this contract and affirms that no services will be performed in Russia. The document requires the contractor to immediately notify the state of any changes in service locations and includes provisions related to Executive Order 2019-12D, which generally prohibits offshore services by state agencies. The form is signed by the company president and dated for a future contract period, indicating an anticipated contract engagement.