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Bidder:'Gibson-Lewis, LLC
<br />I-Plien the pro.sneclirle Contractor is unable It) eerft(y to any of the statements belmv, It shall attach an a plants lon to this A�/7drrvll.
<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 />(Mast be completed for all quotes and bids. please type or print)
<br />STATE Or INDIANA }
<br />) SS:
<br />ST JOSEPH COUNTY }
<br />The undersigned Contractor, being drily sworn upon hisllier/its oath, affirms under the I)enalties of perjury that:
<br />1. Contractor has not, nor has any other member, representative, or agent of the firm,
<br />company, corporation or partnership represented by hitn, 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 corporations has, have or will receive directly or indirectly, any rebate, fee, gift,
<br />commission 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 debarment, declared ineligible, or
<br />voluntarily excluded From participation in this transaction by any Federal department or agency,
<br />and
<br />1 Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in investment
<br />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-M5-5, 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 orits 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 person identified on list publislied 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 verily the work eligibility status of all of
<br />Version 1110912017 Page - 8 Public Works Quote
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