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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 />St. Joseph COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of
<br />perjury that:
<br />Contractor has not, nor has any other member, representative, or agent of the firm, company,
<br />corporation or partnership represented by him, entered into any combination, collusion or
<br />agreement with any person relative to the price to be bid by anyone at such letting nor to
<br />prevent any person from bidding nor to induce anyone to refrain from bidding, and that this
<br />bid is made without reference to any other bid and without any agreement, understanding or
<br />combination with any other person in reference to such bidding. Contractor further says that
<br />no person or persons, firms, or corporation has, have or will receive directly or indirectly, any
<br />rebate, fee, gift, commission 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,
<br />or voluntarily excluded from participation in this transaction by any Federal department or
<br />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 amended
<br />from time -to -time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is
<br />engaged in investment activities in Iran if either:
<br />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 forty-
<br />five (45) days or more, if that person will (i) use the credit to provides goods and
<br />services in the energy sector in Iran; and (ii) at the time the financial institution
<br />extends credit, is a person identified on list published by the Indiana Department
<br />of Administration.
<br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any
<br />employee or contract with a person that the Contractor subsequently learns is an
<br />unauthorized alien. Contractor agrees that he/she/it shall enroll in and verify the work
<br />Version 9/1/2016 Page - 7 Public Works Quote
<br />116-010A Century Center
<br />CEO Suites - Suite 17 Furniture
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