Signed_Affirmation___Disclosure_Form.pdf

This document is an Affirmation and Disclosure Form related to a state contract, specifically addressing requirements for services performed by Russian companies under Executive Order 2022-02D. The form is completed by Signal Service, Inc., located at 1020 Andrew Drive in West Chester, PA 19380, and is associated with the Ohio Department of Transportation (ODOT). The document outlines the contractor's obligations regarding service locations, data management, and compliance with restrictions on Russian companies performing services.

The form indicates that Signal Service, Inc. will perform services at its primary business location in West Chester, PA, with no subcontractors listed. The contractor affirms compliance with Executive Order 2022-02D, which prohibits state agencies from purchasing offshore services from Russian companies. The document emphasizes the contractor's commitment to not perform services in Russia and to immediately notify the state of any changes in service locations or potential violations. The form is signed by the company president on January 3, 2025, and is part of the contractual agreement with the state, specifically addressing geopolitical restrictions on service provision.