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When the prospective Contractor is unable to certify to an r of the statements below, it shall allach an explanation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL <br />PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. I'lease () pe or print) <br />STA'f E OF, , ) <br />SS: <br />si - Jr_ �s 4 k 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, company. <br />corporation or partnership represented by him, entered into am combination, collusion or agreement with <br />any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding <br />nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and <br />without any agreement, understanding or combination with any other person in reference to such bidding. <br />Contractor further says that no person or persons, firms.. or corporation has, have or will receive directly or <br />indirectly, any rebate, fee, gill, commission or thing of value on account ol'such sale: and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its principals <br />are presently debarred, suspended, proposed fbr debarment. declared ineligible, or voluntarily excluded from <br />participation in this transaction by any Federal department or agency; and <br />I Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and any agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as <br />amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor <br />is engaged in investment activities in Iran if either: <br />Contractor, its successor or its affiliate. provides goods or services of twenty <br />million dollars ($20,000,000) or more in value in the energy sector of Iran: <br />or <br />Contractor, its successor or its affiliate, is a financial institution that extends <br />twenty million dollars ($20,000,000) or more in credit to another person for <br />forty-five (45) days or more, if that person will (i) use the credit to provides <br />goods and services in the energy sector in Iran, and (ii) at the time the <br />financial institution extends credit, is a person identified on list published by <br />the Indiana Department of Administration. <br />Version 10/17/2016 Contractor's Bid for Public Works - 4 <br />