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1. Governmental Unit: <br />2. County: <br />3. Bidder (Firm): <br />Address: <br />City/State: <br />(Defined at I.C. 36-1-2-9.5) <br />(Please type or print) <br />J � /� �) Date: <br />1i <br />4. Telephone Number: ��� <br />S. Agent of Bidder (if applicable) f �E <br />Pursuart to notices given, the undersigned offers bld(s) to <br />(Governmental Unit) in accordance with the following aftachment(s) <br />unit, unit price and total amount. <br />specify the class or item number or description, quantity, <br />The contract will be awarded by classes or items, in accordance with specifications. Any changes or alterations in the items <br />specified witl 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 slated 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 />�—v — Signature of der or Agent <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 />Nora-Coflusaon Affidavit <br />STATE OF INDIANA %% SS: j1pe- <br />/ <br />COUNTY OF C�-�-?d <br />The undersigned 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 further 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 />Z lr1 C X. <br />Rdcler (Rrm) <br />�._ Sigrnawm-o H idder or Agent <br />Subscrijed and sworn to before me this l� day of <br />r_ <br />F <br />Notary Public <br />N0REEl' <br />E. LINDESMITH <br />My Commission Expires: <br />• =runty-Stalcoflndi,ini <br />County of Residence: — �uWwlssion Number 703492 <br />My r issiOn Expores Aug 17, 2025 <br />