1-Affirm.212-26.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing requirements for ODOT (Ohio Department of Transportation) under Executive Order 2022-02D. The form is completed by Firelands Supply Co., located in Norwalk, Ohio, and pertains to restrictions on services from Russian companies or institutions. The document requires the contractor to affirm and disclose details about their business location, service performance locations, and state data handling practices.

The form indicates that Firelands Supply Co. will perform services at 18 S. Norwich Rd. in Norwalk, OH 44857, with no subcontractors involved (marked as "N/A"). The contractor agrees to comply with Executive Order restrictions prohibiting the purchase of services from Russian companies, and acknowledges potential immediate contract termination if services are performed outside the United States without proper waivers. The document is signed by Debra Weltie, Vice President, on 6/24/25, and serves as a critical compliance document for state contract engagement.