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CITY OF SOUTH BEND, INDIANA �/; <br />j)�, t.. <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS o; <br />BID NAME 2017 Street and Sewer Department Materials �2 <br />FOR BIDS DUE March 28 2017 9:30 a.m. Local Time <br />ter.= <br />Bidder <br />Date: ftrc.�, 2]�'201-7 (Firm): �2ta ns , . WAkPCuvor�a5 <br />Address: _10-7-7 OlwtC Now Ct <br />City/State/Zip: 5 �{I t��d �tJ y(a(eol Telephone Number. (5 1y) 2S7-Z i�3 <br />Agent of Bidder (if Applicable): 'fow Pal yr 1 f <br />When the prospective Contractor is unable to certify to any of the statemenis below, it shall attach an explanation: to this Affidavit. <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 for all quotes and bids. Please type or print) <br />STATE OF l y,"(Ah 4 ) <br />) SS: <br />$o5P 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, <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 person from bidding nor to induce anyone 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. Contractor further says that no person or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />department or 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 <br />amended from time -to -time. <br />Per. 13 - 6101115 <br />