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CITY OF SOUTH BEND INIDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />BID NAME Spec AD — One (1) or More 2017' or Newer Tandem Axle Multi -Use Dump Trunk <br />FOR BIDS DUE December 12, 2017 at 9:30 a.m. <br />Date: <br />Address: <br />CitylStatelZip: <br />Bidder <br />December 11, 2017 (Firm); Truck Centers, Inc. dlbla Hill Truck Sales <br />1011 W. Sample St. <br />South (Bend <br />Agent of Bidder (if Applicable): Teich <br />Telephone Number: 574 289-4065 <br />nski, Sales Executive <br />When the prospective Contractor is unable to certify to any of the statements belo►v, it shall allacir an a vplanation to this Af ldavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF IN ) <br />) SS: <br />St. Joseph COUNTY <br />The undersigned Contractor, being duly sworn upon his/her/its math, affirms under the penalties of perjury <br />that: <br />1. Contractor: has not, nor has any other: member, representative, or agent of the Firm, <br />company, corporation or partnership represented by him, entered into any combination, <br />collusion or agreement with any person relative to the price to be bid by anyone at such <br />letting nor to prevent any person from bidding nor to induce anyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or: corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value <br />on account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />department or agency; and <br />3. Contractor has .not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />0 <br />