Scan_20250908.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 Berens Tree & Excavating, located at 846 3rd St NW in Massillon, OH 44647. The document addresses requirements under Executive Order 2022-02D, which pertains to restrictions on services performed by Russian companies or institutions.

The form requires the contractor to disclose the location of business, potential subcontractors, and where services and state data will be located. The contractor affirms compliance with prohibitions on purchasing services from Russian companies, stemming from the Executive Order related to the conflict in Russia in 2019-120. The document emphasizes the contractor's commitment to not perform services in Russia and grants ODOT the right to terminate the contract if there are violations. The form was signed by the company president on 9/8/2025, indicating it is part of a broader contractual agreement with the state of Ohio.