CLEAN_Affirmation_and_Disclosure_Form_10.3.25.pdf

This document is an Affirmation and Disclosure Form related to a state contract, involving a contractor located in Columbus, Ohio. The form requires the contractor to affirm understanding of Executive Orders regarding offshore services, state data location, and purchasing restrictions from Russian institutions. The primary business location is listed as 4182 Worth Ave in Columbus, OH 43219, and the location where services will be performed is 11781 St. Route 762 in Orient, OH 43146.

The contractor indicates no subcontractors will be used for this contract, as "Not Applicable" is noted in the subcontractor sections. The form emphasizes the contractor's duty to disclose any shifts in service location before, during, and after contract execution, with the state reserving the right to terminate the contract if services cannot be performed in the United States. The document is signed by Antonio Smith in the role of Director, with a date of 10/3/25, and serves as a formal affirmation of compliance with state contract requirements.