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When the pro.vpective Contrwetor is unable to eertlfy to anlp of the .statemews beloft� it shall attach art asplanation to this Affidavit.
<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 STEED PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF Indiana )
<br />) SS:
<br />Marion COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of pee jury that:
<br />1. Contractor has not, nor has any other member, representative, or agent of the farm,
<br />Company, corporation or partnership represented by him, entered into any combination, Collusion
<br />or atgreelraent 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 from bidding, and that this bid
<br />is made without reference to any other bid and without any agreement, understanding or
<br />combination with any other parson 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 stile, 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 any successor to, nor an affiliate of, Contractor, engaged in
<br />inve,stnlent activities in Iran.
<br />a, For purposes of this Certification, "Iran" means the government of ]ran and any agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from
<br />(mile-to-t i nle.
<br />b. As pr'ovicied lay lnct. Code § 5-22-16.5-8, as aanencicd feotn 1.infi-to-tune, a Contracl.oi, 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 li-an; or
<br />ii. Contractor, its successor or its aMliate, is a finanCiarl 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 />Ncm-CtOutiiun NonA.Jebarrttt-w Affidavit Non Iron Form 2016
<br />03029040.0000 0041 13-3 Addendum No. I
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