|
When the prospective Contractor is unable to eertily to any of the statements belo+q it shall attach an eaPtanation to tfiis Affidtrvlt.
<br />CONTRACTOR'S NON-COLC.IISION AND NON -DEBARMENT AFFIDAVIT,
<br />CERTIFICATION REGARDING I'NVF,STMENT MITI IRAN, EMPLOYMENT EIAGIBILITY
<br />VERIFICATION, NON-DISCRIMINATION COMtMJTMEN'T AND CERTIFICATION OF USE
<br />OF UNITED STALES STEEL, PRODUCTS OR. FOUNDRY PRODUCTS
<br />(Must be corrnpletcd for all quotes and bids. Please type or print)
<br />STATE OF Indiana }
<br />) SS:
<br />Marshall COUNTY )
<br />Tile undersigned Contractor, being, duly sworn upon his/her/its oath, affirms under the penalties of perjury that:
<br />i. Contractor has not, nor has any other member, representative, or agent of fhe firm,
<br />company, corporation or partnership repfescnted 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 chat this bid is uaade
<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 s dll receive directly or indirectly, any rebate, fee, gift,
<br />commission or thing of value on account of such stile; 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 frorn participation in this transaction by any Federal department or agency;
<br />and
<br />3. Contracts Itas not, nor has any successor to, nor an affiliate of, Contractor, engaged in investment
<br />activities in Iran.
<br />a. For purposes of this Ceti ification5 "Irxn" means the government of Iran and any agency or
<br />instrumentality of Iran, or as otherwise defined at -Ind. Code § 5-22-16.5-5, as amended fi-oin
<br />time -to -time.
<br />b. As provided by bid. Code § 5,22-1 Ci.5-8, as amended from time -to -time, a Contractor is
<br />engaged in investment atctivities in Juan if either:
<br />i. Contractor, its successoror.its affiliate, provides goods or services oftwentyruillion
<br />dollars ($20,000,000) or more in vatue.in the energy sector of'lran; or
<br />ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty
<br />million dollars ($20,000,000) or more in credit. to another person for forty-five-, (4.5)
<br />days or more, if that person will (i) use t.Jtc credit to provides goods and sen'ices in
<br />the energy sector in Iran; and (it) at the time the financial institution extends credit, is
<br />a person identified o❑ list published by the Indiana Department of Administration.
<br />4. Contractor does not ltnowingfy employ or contract with, an unauthoriz:;d ali,cn, nor retain
<br />any cruployee or contract with a person that the Contractor subsequently learns is an unauthorized
<br />alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of
<br />Version 10/1812016 Page - 9 Public Works Quote
<br />
|