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When the prospective Contractor is unable to certfbp to any of the statements below, it shall attach an ex-planadall to Ads Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT ENT AFFIDAVIT,
<br />CC,CRTIFICATION IMGA.R]DING DWESTMEN.t WITH RZAN, EMPLOYMENT ELIGIBILITY
<br />E V RMCATION, NQN-DISCRIMINATION COXEMTMENT 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 />St Joseph COUNTY )
<br />The undersigned Contractor-, being duly sworn upon his/her/its oath, affirms under the penalties of perjuty that:
<br />1. Contractor• has not, nor has any other iinember, representative, or agent of the fiinn,
<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 prevent
<br />any person froin bidding nor to induce anyone to refrain from bidding, and that this bid is inade
<br />without referennce 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 />faros, or corporation has, have or will receive directly or indirectly, airy 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 fi•om participation in this transaction by any Federal departnnent 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. For purposes of this Certification, "Iran" meads the governnnient of Ir mi grid any agency, or
<br />instrumentality of Iran, 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 § 5-22-16,5-5, as amended from time -to -true, a Contractor is
<br />engaged in investnieit 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 innore in value in the energy sector of Iran; or
<br />ii. Contractor, its successor of its affiliate, is a financial institution that extends twenty
<br />Brillion 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 Fran; and (ii) at the time the financial institution extends credit, is
<br />a person 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 he/she/it shall enroll in and verify the work eligibility status of all of
<br />Version 11/0912017 page - S Public Works Quote
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