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CITY OF SOUTH BEND INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />BID NAME Spec S -- Janitorial -Cleaning Supplies 2017 <br />FOR BIDS DUE June 27, 2017.9:30 a.m., local time <br />Date: <br />Address: <br />Bidder / <br />r 7 (Firm): Sc�k� j� {-��� <br />City/State/Zip: Telephone Number: <br />Agent of Bidder (if Applicable): , cr t t . 4 <br />When the prospective Contractor is unable to certify to any of'the statements below, it shall attach an explanation to this Affrdayit. <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 />(Most be completed for all quotes and bids. Please type or print) <br />STATE OF''� ) <br />_ ) SS: <br />51, gi COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of petjury <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, firths, 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 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 />4 <br />