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ff'71en thel�raspeable Contractor is rrnrrhle to certify to any of the slatentents below, it sitniinttaeir an explemalim to this 4 iffavif <br />CONTRACTOR'S NON -COLLUSION AND NON-DEBARME, NT A.FFJDAVIT, CERTIFICATION <br />REGARI),ING INVESTMENT WITH MAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL <br />PRODUCTS OR FOUNDRY 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 oath, affirms under the penalties ofpedury <br />that: <br />I. Contractor has not, nor .has any other member, representative, or agent of the Finn, company, <br />corporation or partnership represented by film, entered into any combination, collusion or agreement with <br />any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding <br />nor to induce anyone to xefrain from bidding, and drat this bid is made without -reference to any other bid and <br />without ally agreement, understanding or combination with any other person in reference to such bidding. <br />Contractor further says that no person or pgmons, firms, or corporation has, have or will receive directly or <br />indirectly, any rebate, fee, gill', oommission or thing of value on account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any of'its principals <br />are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from <br />participation. in this transaction by any Federal 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 />a. For purposes ofthis,Certification, "Iran" means the government of Iran and. any agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5.5, as <br />amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor <br />is engaged in investment activities in Iran if either: <br />i. Contractor, its successor or its affiliate, provides goods or services oftwenty <br />million dollars ($20,000,000) or more in value in the energy sector of barn; <br />or <br />ii. Contractor, its successor or its affiliate, is a financial institution that extends <br />twenty million dollars ($20,000,000) or inure in credit to another person for <br />forty-five (45) days or more, if that person will (i) use the credit to provides <br />goods and services in the onergy sector in Iran; and (ii) at: the time the <br />fbiancial institution extends credit, is a person identified on list published by <br />the Indiana Department of Administration. <br />Version 10/1712017 Contractor's Bid for Public Works - 4 Addendum #1 <br />