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NORTHISTAR" <br />11AFFIIDAVIT <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to <br />this Affulav it. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT <br />AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR <br />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 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 <br />of the firm, company, corporation or partnership represented by him, entered into <br />any combination, collusion or agreement with any person relative to the price to <br />be bid by anyone at such letting nor to prevent any person from bidding nor to <br />induce anyone to refrain from bidding, and that this bid is made without reference <br />to any other bid and without any agreement, understanding or combination with <br />any other person in reference to such bidding. Contractor further says that no <br />person or persons, firms, or corporation has, have or will receive directly or <br />indirectly, any rebate, fee, gift, commission or thing of value on account of such <br />sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor <br />nor any of its principals are presently debarred, suspended, proposed for <br />debarment, declared ineligible, or voluntarily excluded from participation in this <br />transaction by any Federal department or agency; and <br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, <br />engaged in investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and <br />any agency or instrumentality of Iran, or as otherwise defined at Ind. Code § <br />5-22-16.5-5, as amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, <br />a Contractor is engaged in investment activities in Iran if either: <br />i. Contractor, its successor or its affiliate, provides goods or services of <br />twenty million dollars ($20,000,000) or more in value in the energy <br />sector of Iran; or <br />NorthStar Proposal Response —South Bend Indiana <br />