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When theprosImclive Contractor is unable to certify to any of the statements beloiv, it shall attach an-explanallon to this Affidavit.
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<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 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, collusion
<br />or agreement with any person relative to the price to be bid by anyone at such letting nor to
<br />prevent any person from bidding nor to induce anyone to refrain fi-om bidding, and that this bid
<br />is made without reference to any other bid and without any agreement, understanding or
<br />combination with 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 indirectly, any
<br />rebate, fee, gift, commission or thing of value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
<br />voluntarily excluded from participation in this transaction by any Federal department or agency;
<br />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 agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from
<br />time -to -time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is
<br />engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty million
<br />dollar-, ($20,000,000) or rnore in value in the energy sector of Iran; or
<br />ii. Contractor, its successor or its affiliate, is a financial institution that extends twenty
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />days or more, if that pet -son will (i) use the credit to provides goods and services in
<br />r-Non-Cofl usion Non-Debaffnelit Af1udav it Non Iran Forin 2012
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