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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />BID NAME <br />FOR BIDS DUE <br />/ Bidder <br />Date: �a�cl Q L©l� (Firm): <br />Address: ZL lS S. A4/ : n <br />City/State/Zip: <br />Agent of Bidder (if Applicable): <br />Telephone Number: <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an 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 yncti� u ) <br />SS: <br />S�•ed COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury 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 agreement with <br />any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding <br />nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid <br />and without any agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or corporation has, have or will receive <br />directly or indirectly, any 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 principals <br />are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded <br />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 investment activities <br />in 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 from time -to - <br />time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is engaged in <br />investment activities in Iran if either: <br />