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Rescrthed by the State Hoard M Accounts - Form No. 96 tRerised 1987) <br />Bid, er or Proposal for Sale or Lease of Materials <br />1. Governmental Unit: <br />2. County: <br />3. Bidder (Firm): <br />Address: <br />City/State: <br />4, Telephone Number: <br />5. Agent of Bidder (if applicable) <br />(Defined at I.C. 36-1-2-9.5) <br />(Please type or print) <br />Date <br />�33? <br />i <br />� <br />r i^•. > V �,.. <br />7- <br />Pursuar-t to notices given, the undersigned offers bids) -to,. <br />(Governmental Unit) in accordance with the following attachment(s) which specify the class or item number or description, quantity, <br />unit, unit price and total amount. <br />The contract will be awarded by classe.s,.or items, in accordance with specifications. Any changes or alterations in the items <br />specified wil render such bid void as to that class or item. Bidder promises that he has not offered nor received a less price than the <br />price stated in his bid for the materials -included in said bid. Bidder further agrees that he will not withdraw his bid from the office in <br />which it is filed. A certified check or bond shall be filed with each bid if required, and liability for breach shall be enforceable upon <br />the contract_ the bond or certified check or both as the case may be. <br />sign tt a of Bi der or Agent <br />Bid Offer or Proposal <br />Attach separate sheet listing each item bid based on specifications published by governing body. Following is an example of <br />the bid format: <br />Class or Item Quantity Unit Description Unit Price �Appmount <br />lit i lyt� z& 'V <br />f 6ij , <br />Non -Collusion Affidavit - I -- <br />STATE OF IIr.DIANA ) L_ l <br />i 19 <br />SS: <br />COUNTY OF r�il <br />The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative, or <br />agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement <br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to induce anyone <br />to refrain frcm bidding, and that this bid 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. <br />He further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, <br />gift, commission or thing of value on account of such sale. <br />1�` - <br />Bidder (Firm) <br />Subscri-ned and sworn to before me this 1 ) day of <br />My Commission Expires: _ J C- G - <br />County of Residence: <br />§!gaature of Bidder or Agew"`� J 01g1V <br />�yPublic o`pnv ao: <br />i 'zN. <br />F4fpcom("y4 ej <br />TE, OF <br />//����Illrllllllll4����, <br />