signed_aff___disc.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically involving Statewide Western Star of Ohio as the contractor. The form is tied to Executive Order 2022-12D, which addresses restrictions on services performed by Russian companies or institutions. The document is prepared for ODOT (Ohio Department of Transportation) and requires detailed disclosure about the contractor's business locations, service performance sites, and data storage locations.

The form confirms that the contractor (Statewide Western Star of Ohio) will perform services at 1770 Wapak Fisher Rd in Wapakoneta, Ohio 45895, with no subcontractors listed. The contractor affirms compliance with Executive Order restrictions, specifically prohibiting the purchase of offshore services by state agencies from Russian companies. The document is dated 9-24-2022 and was signed by David Hilbner in the role of Sales Manager, demonstrating the company's commitment to adhering to state contractual requirements and geographical service performance restrictions.