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CITY OF SOUTH BEND, INDIANA. <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />BID NAME 2,018 Street and Sewer Department Materials <br />FOR BIDS DUE April 10, 2018, 9:30 am., Local Time <br />Bidder <br />Date: (Firm): kt)EP4 &Y-Kc-4-6 tw_ <br />Address: '6qo'z Nee J.&JUjAu We4 <br />F_VC_J�N r <br />City/State/Zip: JAIPA&Lb 1 ITelephone (Number: (5*7q) '4-9911 <br />Agent of Bidder (if Appflcable): M kiLLt-:?, - Ylte _PRGSlVG"+ oP SALC<, <br />When the prospeediv Contraetor is unable to cert?fjy to any of the statements belo)v, It shall attach an e-,vp1anation to this Affidaiit. <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 />I <br />STATE OF <br />SS: <br />COLJNTY <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms Linder 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 hire, 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. Conti -actor 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 <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-,5, as <br />amended from time -to -time. <br />Tler. 13 - 6101115 <br />