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When the prospective Contractor is unable to certify, to any of the statements belokv, it shall attach an explanation to this Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -(DEBARMENT AFFIDAVIT,
<br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY
<br />VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE
<br />OF UNITED 'STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATIC OF
<br />) SS:
<br />,T, b- .,. COUNTY )
<br />The undersigned. Contractor, being duty sworn upon his/her/its oath, affirms under the penalties of perjury that:
<br />I. 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 from 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 />8. 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 or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-I6.5-5, as amended from
<br />time -to -time.
<br />b, As provided by Ind, Code § 5-22-1.6.5-8, 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 />dollars ($20,000,000) or more 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 person will (i) use the credit to provides goods and services in
<br />I Dion -Collusion Non -Debarment Affidavit Non Iran Form 2012
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