OH_DOT_Affirmation_and_Disclosure_Form_4.25_Final.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically involving the Ohio Department of Transportation (ODOT). The form is completed by Henderson Products, Inc., a contractor located in Manchester, Iowa, with a service location in Buyrus, Ohio. The document addresses compliance with Executive Order 2022-02D regarding restrictions on services performed by Russian companies or institutions, emphasizing that no services will be performed in Russia.

The contract service location is specified as 2177 State Route 19 in Buyrus, Ohio, with state data to be located at the contractor's primary business address in Manchester, Iowa. No subcontractors are listed, and the form indicates that the contractor agrees to notify the state of any changes in service locations or contract terms. The document is signed by the Contract Administrator, Kathleen Weber, with an execution date of 4/30/2025, and serves as a formal affirmation of the contractor's commitment to contract terms and geographic service restrictions.