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Bidder: -Gibson-Lewis, LLC <br />When the prospective Contractor Is tenable to certify to rrnp of the statenrents below, It shrill attach an erplrutallon to this A fff�lrn ft. <br />CONTRACTOR'S NON -COLLUSION AND NON-DE'BARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBI[L]TY <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 INDIANA ) <br />) SS: <br />ST JOSEPH COUNTY ) <br />The undersigned Contractor; being duly sworn upon his/her/its oath, affirms sender the penalties of perjury that: <br />1. Contractor has not, nor has any other member, representative, or agent of the firth, <br />company, corporatiort 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 prevent <br />any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made <br />without reference to any other bid and without any agreement, understanding or combination with <br />any other person in reference to such bidding. Contractor further says that no person or persons, <br />firms; or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, <br />con -mission 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 debarrnent, 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 an affiliate of, Contractor, engaged in investment <br />activities in Iran. <br />a. [-or purposes of this Certification, "Iran" means the government of .tram and any agency or <br />instrumentality of gran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from <br />time -to -time. <br />b. As provided by Ind. Code § 5-22-1 G.5-8, as amended 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 twenty <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 in <br />the energy sector in Iran; and (ii) at the time the Financial institution extends credit, is <br />a parson identified on list published by the Indiana Department of Administration. <br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain <br />any employee or contract with a person that the Contractor subsequently learns is an unauthorized <br />alien. Contractor agrees that lie/she/it shall enroll in and verify the work eligibility status of all of <br />Version 11/09/2017 Page - 8 Public Works Quote <br />