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V o 'LIM pj M t4 I�Tjj I grill wiralkiffIROMIjil I jLTjj jigo <br />V U <br />131n, 2018 at 9:30am <br />Date: 2_ 6 .1 y Firm: <br />11 ori- <br />Address: .9- y -) 4 0 1 C1 (A Ve � I- <br />citylstate/zip: 4t�­jt, Telephone Number: (5-79 ) Q-93 <br />Agent of Firm (if Applicable): 'j3j-c,j <br />Wien theprosI)ective Contractor is unable to certiy� to atti, of the statements belo;v, it shall affitch an explanation to thh Affidavit. <br />j <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 <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 />I . 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, Conti -actor 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 trait. <br />Version 8 — 02/25/14 <br />