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CITY OF SOUTH BEND, INDIANA <br />SELLER'S QUOTE FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />QUOTE NAME Centu!y Cenler Lift Equipment <br />FOR QUOTES DUE, February 13 In , 2018 at 9:30am <br />Date: all 1 (8— Firm <br />Address: (q. cil"Ve <br />City/State/Zip: 6-9, _ff4 q6619 Telephone Number: <br />Agent of Firm (if Applicable): -I-As 1>" 1104 <br />mmv�� <br />When the prospective Contractor is unable to certify to any of the statements belosv, it shall allach an exlVanation 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 />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />'�f 1 <br />STATE OF 441 <br />SS: <br />COUNTY <br />The undersigned Conti -actor, being duly sworn upon his/her/its oath, affirms under the penalties of pcjjury <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. 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 or 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 />Version 8 — 02/25/14 <br />