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When the prospective Contractor is unable to certify to any of the statements below, it shall attach an
<br />explanation to this Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AFFIDAVIT, NON -DEBARMENT AFFIDAVIT,
<br />EMPLOYMENT ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT FOR
<br />CONTRACTORS AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS
<br />OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF INDIANA )
<br />) SS:
<br />La Po/fc�, COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties
<br />of perjury 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 bidding,
<br />and that this bid is made without reference to any other bid and without any agreement,
<br />understanding or combination with any other person in reference to such bidding.
<br />Contractor further says that no person or persons, firms, or corporation has, have or will
<br />receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account
<br />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 agency
<br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as
<br />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 />ii. Contractor, its successor or its affiliate, is a financial institution that extends
<br />twenty million dollars ($20,000,000) or more in credit to another person for
<br />forty-five (45) days or more, if that person will (i) use the credit to provides
<br />goods and services in the energy sector in Iran; and (ii) at the time the financial
<br />institution extends credit, is a person identified on list published by the Indiana
<br />Department of Administration.
<br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain
<br />any employee or contract with a person that the Contractor subsequently learns is an
<br />Version 9/1/2016 Page - 17 Public Works Quote
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