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CITY OF SOUTH BEND IN <br />R'S BID FOR SALE OR LEASE <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />Spec AH — One (1) or More New your Wheel Drive Compact Tractor With Quick Release <br />BID NAME Loader Bucket <br />FOR BIDS DUE December12, 2017 at9:30 a.m. <br />Bidder <br />Date; (Firm): eI Ck �%� l�l�Gt <br />Address: 3& 3C) �-GS L� � , <br />City/state/Zip: <br />Agent of Bidder (if Applicable): <br />ephone Number: <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit. <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 :rvjtv c, ) <br />SS: <br />�� COUNTY } <br />The undersigned Contractor, being duty 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, <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 fi-om <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 fiuther says that no person or persons, fitms, 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 />Ver. 2 — 4/16/12 <br />