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r-rescribed oy the Stale Board of Accounts <br />Form No. 95 (Revised 1987) <br />(Defined of I.C. 36-1-2-9.5) <br />(Please type or print) <br />i <br />1. Governmental Unit: <br />' <br />2. County: S_ ._.._.�-� �; e" � /'/ <br />3. Bidder (Firm): �V /C'� <br />Address: <br />• iV- 7 G� <br />City/State:Zy <br />Date: <br />4. Telephone [Number: <br />5. Agent of Bidder (if applicable) <br />/.J Lf. j % 1 <br />Pursuart to notices given, the undersigned offers bid(s) to <br />(Governmental unit) in accordance with the following attachment(s) which spe ify the class or item number or description, quantity, <br />unit, unit price and total amount. <br />The contract will be awarded by classes or items, in accordance with specifications. Any changes or alterations in the items <br />specified witt render such bid void as to that class or item. Bidder promises that he has not offered nor received a less price than the <br />price stated in his bid for the materials included in.said bid. Bidder further agrees that he will not withdraw his bid from the office in <br />which it is filed. A certified check or bond shall be filed with each bid if required, and liability for breach shall be enforceable upon <br />the contract., the bond or certified check or both as the case may be. <br />j <br />Signalufeof-dder or Ag nt <br />j• � (#I i�l 1 r ' (�I I �^l i� 1�3 i# �Mi , r. <br />Attach separate sheet listing each item bid based on specifications published by governing body. Following is an example of <br />the bid format'. <br />Class or Item Quantity Unit Description Unit Price Amount <br />'� <br />Mon -Collusion Affidavit <br />STATE OF INDIANA � <br />SS: <br />COUNTY OF (�-,n/C <br />The uncersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member, representative, or <br />agent of the firm, company, corporation or partnership represented by him, entered into any combination, collusion or agreement <br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding nor to induce anyone <br />to refrain frcm bidding, and that this bid is made without reference to any other bid and without any agreement, understanding or <br />combination with any other person in reference to such bidding. <br />He furtt-er says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, <br />gift, commission or thing of value on account of such sale. <br />-_---Ridd-r (Firm) <br />-SfrFAtiJie`ot Bid` a or Agent <br />� ,�."i,.y <br />Subscriaed and sworn to before me this f day of , 20 <br />1 I j: '/...'. <br />Notary Public <br />NOJI F.EN E. LINDESMITH <br />N,)Ciry Public - Scaf <br />My Commission Expires: <br />a n,mission Number 703492 <br />C nrrnhr of >7aairiranres k X11,1 Commission Expires Auq 17. 2M <br />