Shelly_Southern_Affirmation___Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to an Ohio Department of Transportation (ODOT) contract, completed by Shelly Materials. The form addresses compliance with Executive Order 2022-02D, specifically focusing on restrictions regarding services performed by Russian companies or institutions. The contractor (Shelly Materials) is based in Thornville, Ohio, and has provided their principal business location and contact information for potential contract work.

The form indicates that Shelly Materials will perform services at 80 Perk Dr in Thornville, OH 43076, with no subcontractors listed (marked as "N/A"). The document emphasizes the contractor's commitment to not use Russian companies or subcontractors for services, in line with the state's prohibition stemming from Executive Order 2019-12D. The form serves as a legal affirmation that the company understands and will comply with contract requirements, including immediate disclosure of any changes in service locations and potential contract termination if requirements are not met. The document was signed by the Vice President on 2-25-25, indicating the company's formal acknowledgment of these terms.