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Wien the prospective Contractor is inrable to eerllfyt to any of Ike statements helom, it shall atlach an explanation to this tiff irkrvit,
<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 OF�',4I /E046,,ld }
<br />) Ss:
<br />COUNTY }
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of pe€ jury 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, 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 front bidding, and that this bid
<br />is trade 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, firms, or corporation has, have or will receive directly or indirectly, any
<br />rebate, fee, gift, commission or thing of value on account of such sate; 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 ally 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 agency or
<br />instruineritality of 1€•an, or as otherwise defined at Ind. Code § 5-22-1 G,5-5, as amelyded fro€n
<br />time -to -time.
<br />b. As provided by lid. Code § 5-22-16.5-8, as amended front time-to-ti€ne, 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 t%venty 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 twenty
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />clays or more, if that person will (i) use tine credit to provides goods and services in
<br />Nim-Collusion Non-llebarmont A€ridavil Non Iran Form
<br />
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