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CITY OF SOUTH BEND INDIANA <br />IUOTE FOR SALE OR LEASE OF MATE <br />.USION AND NON DEBARMENT AFFID, <br />QUOTE NAME Century Center Lift E ui ment <br />FOR QUOTES DUE Februa ' 13th 2018 at 9:30am <br />Date: 'Z 12618 Firm:raCCtiso�N(��nsCi� �,,► 1ti��"� <br />Address: eZ,505 Obo -�, <br />City/State/Zip: S_Dws & �ZkAgbv6 Telephone Number: _{ S7 } %. b I - qZ13 U <br />Agent of Firm (if Applicable): <br />When the prospective Contractor Is unable to cerl& to any of the statements below, It shall allacli on explanation to this Affldavit. <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 .11 <br />)SS.. <br />`� u512 t, COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/herl.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 on <br />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 />Version 8 — 02/25/14 <br />