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yY ' iij <br />CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS Y <br />a <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />BID NAME Spec H Ten (10) More or Less Commercial Riding Mowers <br />FOR BIDS DUE April 11, 2017 at 9:30 a.m. r <br />, / <br />Date: { (Fidrrn}; fVr ��a.� �c�� G{5/' %/jM t�/�A. af u�`�-%a1c1 <br />Address:!_._N� {/ds 17 <br />City/State/Zip: FlkGg k Telephone Number: (s-)y <br />Agent of Bidder (if Applicable): <br />Wlrelr the pf'pspBCtiVB CO1rIYQCrOf IS lllrll6lL' 1D CC17ify to any of the strrlerrrelrts belorv, it sJrltl7 rtttltclr an expfttlrativrr to this Ifffrdavit. <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 -r."_f V! _� ) <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 />I . 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 <br />on 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 frorn 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 />4 <br />