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<br />CITY OF SOUTH BEND. INDIANA °4' All
<br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS o.
<br />BID NAME 2016 South Bend Police Vehicle Equipment a`
<br />FOR BIDS DUE 9:30am on August 23, 2016 x65
<br />// Bidder
<br />Date: g— / 9 — � b (Firm):
<br />Address: R 2n C-AM ,J 'A, , 12
<br />✓yCl li'i}'t! Ir �i i lee ( L�-,W Iv�ri'1e nT
<br />City/State/Zip: fV iajrj,Ap�JiT �. 44X hone Number. (S'17) 63S-'r"G�t�
<br />Agent of Bidder (if Applicable): Mike-
<br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation
<br />to this Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION
<br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-
<br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL
<br />PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF _tIV )
<br />/�^ )
<br />/' et r i SS: o � COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury
<br />that:
<br />Contractor has not, nor has any other member, representative, or agent of the firm,
<br />company, corporation or partnership represented by him, entered into any combination,
<br />collusion or agreement with any person relative to the price to be bid by anyone at such
<br />letting nor to prevent any person from bidding nor to induce anyone to refrain from
<br />bidding, and that this bid is made without reference to any other bid and without any
<br />agreement, understanding or combination with any other person in reference to such
<br />bidding. Contractor further says that no person or persons, firms, or corporation has,
<br />have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of
<br />value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debarment, declared
<br />ineligible, or voluntarily excluded from participation in this transaction by any Federal
<br />department or agency; and
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investment activities in Iran.
<br />a. For purposes of this Certification, "Iran" means the government of Iran and any
<br />agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5,
<br />as amended from time -to -time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor
<br />is engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty
<br />million dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />Bidder'Ver. 12 — 9/16/13
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