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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS =r,' <br />':' , " t.,I, , <br />BID NAME Ductile Iron Pipe, Gate Valves, & Fire Hydrants <br />FOR BIDS DUE Aril 11, 2017 at 9:30 a.m. <br />Bidder <br />Date: r( 0 Zv (Firm): �7er 4S�L. w c 5 <br />Address: t <br />City/State/Zip: Sn nk�(�p h�i, jt•{ �((PCaC�I Telephone Number: (5-7j) ?_2z—Z3 Z 3 <br />Agent of Bidder (if Applicable): lfo L, J '&-I'c <br />When lire prospective Contractor is unable to certify to any of the statements belo►v, it shall attach an exploitation 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 <br />SS: <br />. 505k COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />l . 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-I6.5-5, as <br />amended from time -to -time. <br />Ver, 13 — 6101115 <br />