|
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 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 Indiana )
<br />) SS:
<br />St. Joseph COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its 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, 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 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,
<br />commission or thing of value on account of such sale; and
<br />2. iContractor certifies by submission of this proposal that neither contractor nor any of its principals
<br />are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily
<br />excluded from participation in this transaction by any Federal department or agency; and
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investment activities to Iran.
<br />a. For purposes of this Certification, "Iran" 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
<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 />t. 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 unauthorized
<br />alien. Contractor agrees that helshe/it shall enroll in and verify the work eligibility status of all of
<br />Contractor's newly hired employees through the E-Verify Program as defined by I.C. 22-5-1.7-3.
<br />Contractor's documentation of enrollment and participation in the E-Verify Program is included
<br />Version 10/17/2016 Contractor's Bid for Public Works - 4
<br />
|