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When likeprospedipeConfraclor Is unable, to Verilty to any, of ffrasfaferatertfs beloiv, It skull attach an explarindan to &IN4#7110 Pit
<br />CONTRACTOR'S NON-COLLUStON AND NONM nARMENT AFFIDAVIT,
<br />CERTIFICATION RE, GARDING INVIC, STMENT WITH WAN, E MPLOYMENT E LIGIBILITY
<br />WE RIFICAT10N, NON-IMCRIMINATION COMMITMENT AND:mfincAmN OF USE
<br />OF UNITED STATES" $TEX L PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. please type or print)
<br />STATE OF
<br />SS:
<br />COUNTY
<br />The undersigned Contractor, being duty sworn upon his/her/its oath, affirms trader thepeo-alties of perjury the
<br />I I Contractor has not, nor has any other member, representative, or agent of the firm,
<br />company, corporation or partnership roptesented by -him, entered into any combination, collusion
<br />or agreement with any person relative to the price to be bid by anyone at such letting nor to
<br />prevent any person ftoM bidding nor to. induce anyone to refrain from bidding, and that this bid
<br />is made without re�fercnce to any other bid and without any agreement, understanding or
<br />combination with any other person in reference to such bidding. Contractor further says that no
<br />person or persons, firms, of corporation has, have or will rmeive directly of indirectly, any
<br />rebate, fee, gift, commission or thing of value on account of such sale; and
<br />I Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals, are presently, debarred, suspended, proposed for debarment, declared ineligible, or
<br />voluntarily excluded from pdrticiPatioll in this transaction by any Federal department or agency;
<br />and
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, ongaged in
<br />investment activities in Iran.
<br />ao For purposes of this Certification, "Iran" rucarIs the government of Iran and any agency or
<br />instrumentality of [ran, or as otherwise defined at hid, Code § 5-22-10.5-5' as amended from
<br />finle-to-thne.
<br />6. As provided by Ind. Code § as amonded from timeAo-time, a Contractor is
<br />engaged in investment actiVitles in. Iran if 04116r.,
<br />i. Contractor, its successor oritA affiliate, provides goods or services of twenty million
<br />dollars ($20,000000) or more it, value in the oacjgy sector of Iran; or
<br />ii. 'Contractor, its successor or its affiliate, is a financial institution that extends twenty
<br />million do I tars, ($20,000,000) or more in credit to another Person for forty-five (45)
<br />days,or more, if that person will-(i) use the credit to provides goods and services in
<br />Now(l,b1holon Noa-Mijannent AMAQ NO Imn FuLM
<br />ZEXPERIENCES 32
<br />BUILT
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