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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 AA - Two (2) More or Less 2017 or Newer Utility Crew Trucks <br />FOR BIDS DUE October 10, 2017 at 9:30 a.m. <br />Date: to I & /,?,D r -I <br />Address: 2-705 Al- M i C <br />City/State/Zip: t 14 MOA, -M <br />Bidder NW Caok+-,, ,A fi <br />(Firm): M04 <br />in coukhri C hevra lC fly` Ce��er <br />a� 5�, / JP0 Bp53 0 <br />r<P3 Telephone Number: __574) 93 & - Z 1 fS <br />Agent of Bidder (if Applicable): 0e_ HC Ckiy)._�, <br />When the prospective Contractor is unable to certify to any of the statements belo;v, it shall attach an explanation to this Affidavit. <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 />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF J ►" <br />SS: <br />M Qrsha 1 j COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <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, firms, 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 lean. <br />M <br />