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When the pra.speclive Contractor is unable to certify to an), of the .statements heloiip, it shall attach an explanation to Ibis Affidarit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT,
<br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY
<br />VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE
<br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE Oh Indiana )
<br />St. Joseph COUNTY ) SS:
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that:
<br />I. Contractor has not, nor has any other mernber, representative, or• agent of the firm,
<br />company, corporation or partnership represented by him, entered into any combination, collusion
<br />or agreement with any person relative to the price to be bid by anyone at such letting nor to
<br />prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid
<br />is made without reference to any other bid and without any agreement, understanding or
<br />combination with any other person in reference to such bidding. Contractor further says that no
<br />person or persons, firrtns, or corporation has, have or will receive directly or indirectly, arty
<br />rebate, fee, gift, commission or thing of value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
<br />voluntarily excluded from participation in this transaction by any Federal department or agency;
<br />and
<br />3. Contractor has not, nor has any successor to, nor ail affiliate of, Contractor, engaged in
<br />investment activities in Iran,
<br />a. l,or purposes of this Certification, "Iran" means the government of Iran and any agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as antended frorn
<br />time -to -time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as antended from time -to -time, a Contractor is
<br />engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty million
<br />dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />ii. Contractor, its successor or its affiliate, is a financial institution that extends twenly
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />days or more, if that person will (i) use the credit to provides goods and services ill
<br />the energy sector in Iran; and (ii) at the tinge the financial institution extends credit, is
<br />a person identified on list published by the Indiana Departinent of Administration.
<br />4. Contractor does not knowingly employ or contract with ail unauthorized alien, not- retain
<br />any employee or contract with a person that the Contractor subsequently learns is an
<br />unauthorized alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility
<br />Version 10/18/2016 Page - 10 Public Works Quote
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