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REVISION 3 <br />When the prospective Contractor Is unable to certify to any of the statements below, It shall attach an explanation to this <br />Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING <br />INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-DISCRIMINATION <br />COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF, Indiana ) <br />........... . <br />)SS.. <br />St. Joseph COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of <br />perjury that: <br />1. Contractor has not, nor has anyother member, representative, oragent of the firm, company, <br />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 <br />from bidding nor to induce anyoneto refrain from bidding, and that this bid is made without reference <br />to any other bid and without any agreement, understanding or combination with any other person in <br />reference to such bidding. Contractor further says that no person or persons, firms, or corporation <br />has, have or will receive directly or Indirectly, any rebate, fee, gift, commission or thing of value on <br />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; 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 and any <br />agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, <br />as amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a <br />Contractor Is engaged in investment activities in Iran if either: <br />1. Contractor, its successor or its affiliate, provides goods or services of twenty <br />million dollars ($20,000,000) or more in value in the energy sector of Iran; <br />or <br />il. Contractor, its successor or its affiliate, Is a financial institution that extends <br />twenty million dollars ($20,000,000) or more in credit to another person for <br />forty-five (45) days or more, if that person will (1) use the credit to provides <br />goods and services in the energy sector in Iran; and (h) at the time the <br />Version 10117/2016 Contractor's Bid for Public Works - 5 <br />