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c,C7iF.t1]l . <br />CITY OF SOUTH BEN® INDIANA <br />J <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />DID NAME 2014 UNIFORM AND FLOOR MAT SERVICE AHD RENTALS "r <br />FOR BIDS DUE September 23, 2014; 9:30 a.m. x <br />865 <br />C�j Bidder <br />Date: �1 f a,-,)_aD A (Firm): Lit. -M7,5 LD <br />Address: - <br />City/State/Zip: III '4WAelephone Number; !S-14 J � <br />Agent of Bidder (if Applicable): W IA <br />When the prospective Contractor is unable to certify to any of the statements helow, it shall attach art 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 />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF } <br />SS: <br />COUNTY ) <br />The undersigned Contractor, being duly 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 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 />a. For purposes of this Certification, "Iran" means the government of Iran and any <br />agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, <br />as amended from time -to -tithe, <br />