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0cf.28. 2016 1:36PM <br />QUOTE NAME Two (2) All Tern <br />FOR QUOTES DUE November 8, 20' <br />Date: �% ' % Firm. <br />Address' 011� E: /VwshR <br />No.1543 P, 2/0' <br />SOX] 14 <br />ND <br />1865 <br />-§-6RrJ <br />City/State/Zip; Cf� r i/ 9�f- Telephone Number: (Plf ) a 9 5-- <br />Agent of Firm (if Applicable): �@l f an �rk✓�7C�� <br />When the prospective Contractor Is unable to cerill 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, NOW <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 1 ✓t/ ) <br />SS: <br />IK COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/herlits oath, affirms under the penalties of perjury <br />that: <br />1. 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, collusion <br />or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent <br />any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made <br />without reference to any other bid and without any agreement, understanding or combination with <br />any other person in reference to such bidding. Contractor further says that no person or persons, <br />firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission <br />or thing of 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 Ineligible, or <br />voluntarily excluded from participation in this transaction by any Federal department or agency; <br />and <br />1 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 § 5-22-10.5-8, 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 />Version 8 — 02/25/14 <br />