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BID NAME <br />FOR BIDS DUE <br />CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />Equipment Purchase For Nello Corporation Phase XVI <br />Project No. 116-137 <br />Bidder <br />Date: /Z O f (Firm): %/� G�7/GO/r✓F/SIG G4�O,QYy <br />Address: SF ✓ram B <br />City/State/Zip: leaB4Np P v�,/Y�) 5�9iJy Telephone Number: (6/% 299—J, 6D`J <br />Agent of Bidder (if Applicable): <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explifirhiliuh to this <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN , EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed foall quotes andbids. Please type or print) <br />STATE OF ) <br />SS: <br />COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />1. Contractorhas not, nor has any other member,eepntative, 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 pH)n from biddingnor to induceanyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractorfurther says that no personparsons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value <br />on account of such saland <br />2. Contractorcertifies by submission of this proposal that neither contratdDany <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by Faederal <br />department or agency; and <br />3. Contractor has not, nor has any successor to, nor an affffaContractor, engaged in <br />investment activities in Iran. <br />