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.. ............ <br />CITY OF SOUTH BEND INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />INS �,O' <br />­�(, liki� ; <br />NO N-DISCRIMI NATION COMMITMENT FOR SELLERS <br />BID NAME Spec 0 - Two (2) More or Less 2018 or Newer Refurbished Medic Units <br />FOR BIDS DUE Mav 22, 2018 at 9:30 a.m. <br />Bidder <br />Date� /11 e,�) I (Firm): <br />It P I A &.7-, �� " g iZ e., <br />_L15 1641,1054_-NIAS TI-tvC, <br />Address: 01 5' <br />City/State/Zip: Zj cit 3'13 Telephone Number ?,40 ) 6514 q <br />'T <br />Agent of Bidder (if Applicable)� <br />When theprospeelive Contraefor Is unable to eerlify to ony of the statements below, it shall atlach an explanation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION -RE GARDING 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 />STATE OF X'�odmAJ_A <br />) SS: <br />IM A-1zjp L0 COtJNTY <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of periury <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 him, 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 <br />on 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. Contractor has not, nor has any successor to, nor an affifiate of, Contractor, engaged in <br />investment activities in Iran, <br />51 <br />