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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />BID NAME D <br />FOR BIDS DUE A <br />le Iron Pipe, Gate Va <br />11, 2017 at 9:30 a.m. <br />& Fire Hydrants <br />IAW I it jf�'. <br />f <br />Gi <br />Y <br />Bidder <br />Date:' ! 7 I (Firm): D <br />Address: ©Y3 c J-, <br />City/StatelZip:,1/�1�3'%Telephone Numher:i <br />Agent of Bidder (if Applicable): <br />When the prospective Contractor is unable to certify to any of the statements helaiv, it shall attach an explanation to this Affrdavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH 1[RAN, 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 ,-:77-I) <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. Contractor has not, nor has any other member, representative, or agent of the `IiHi, <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:._w.ithout .any. <br />agreement, understanding or combination with any other person in reference to :such <br />bidding. Contractor hirther says that no person or persons, firms, or corporations 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 />1 Contractor certifies by submission of this proposal that neither contract& nbr 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 Fed"thl <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 aril ,hy agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-I633-�;'izs <br />amended from time -to -time. ` ; � <br />Vu r .13 61,0185 <br />