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molgi; I I PR2 pig �' lull irge <br />Date: <br />A�ddress: <br />City/State/Zip.' 1W f-c <br />Agent of Bidder (if Applicable): <br />,2018 <br />Bidder <br />(Firm): <br />UE <br />Telephone Number <br />62 7-, 00 0 <br />When theprospective Contractor Is unable to certify to any of the statements belo)v, itshall attach an explanation to thisAffidavit. <br />CONTRACTOR'S NON-COLLUSIOX AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION RE, GARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITME NT AND <br />CERTIFICATION OF USE OF UNITE D STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />sTATr�, o F lv v 1 s <br />SS: <br />2-1v <br />The undersigned Contractor, being duly sworn upon his/hor/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 finn, <br />compally, corpora(ion ol, partnurship roproswited by him, entered into any combination, <br />C011USion or agrecinclilt will, tiny person relative to the price to be bid by anyo,no at such <br />letting nor to prevent any person from biddiiig, nor to induce anyone to re)[1-ain ftom <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 110 lk"S011 or persons, firinS, or corporation lim, have <br />of Will receive directly or indircOdY, any robate, fee, git't, collimission or thing o['value <br />on account of such sale; and <br />I Conti,actor cor(ifics by submissioll of this proposal thatticither conh.,10(01' norany <br />of its principals are presently debarred, SUS11011dCd, I)t,oposed for debarment, declared <br />ineligible, or vok,"ta"i'lY excludcd from participation it, this tran�aetion by any Vcderal <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 />