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Illhen Ilse pr'ospecthr e Contractor is unable to certifj to ru{I of the statements below, it shall attach an explanation in this Ajfidat%
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION
<br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-
<br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL
<br />PRODUCT'S OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF INDIANA )
<br />) SS:
<br />ELKHART 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, company,
<br />corporation or partnership represented by him, entered into any combination, collusion or agreement with ally
<br />person relative to the price to 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 to any other bid and without
<br />any agreement, understanding or combination with any other person in reference to such bidding. Contractor
<br />further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly, any
<br />rebate, fee, gift, commission or thing of value oil account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its principals are
<br />presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from
<br />participation in this transaction by any federal 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 />For purposes of this Certification, "Iran" means the government of Iran and any agency
<br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended
<br />froth tithe -to -time,
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from tine -to -tithe, 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
<br />million dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />iL Contractor, its successor or its affiliate, is a financial institution that extends
<br />twenty million dollars ($20,000,000) or more in credit to another person for
<br />forty-five (45) days or more, if that person will (i) use the credit to provides
<br />goods and services in the energy sector in Iran; and (ii) at the time the financial
<br />institution extends credit, is a person identified on list published by the Indiana
<br />Department of Administration.
<br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain any employee
<br />or contract with a person that the Contractor subsequently teams is an unauthorized alien. Contractor agrees
<br />that he/she/it shall enroll in and verify the work eligibility status of all of Contractor's newly hired employees
<br />Version 10/17/2017 Contractor's Bid for Public. Works - 4
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