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00,1111 4, 't� <br />CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON-COLLUSION1 AND NON DEBARMENT AFFIDAVIT'AND M65 <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />Spec R — One (1) or more 2018 or Newer Combination Jet Rodder/Vacuum Machine with, <br />BID NAME Cab & Chassis <br />FOR BIDS, DUE June 12, 2018 at 9:30 a.m. <br />Bidder <br />Date: JUNE 8, 2018 (Firm): JACK DOHENY COMPANIES, INC. <br />Address- P.O� BOX 6019 <br />City/State/Zip: NORTHVILLE, MI 48167 Telephone Number: ( 248 ) 349-0904 <br />Agent o�f Bidder (if Applicable): MIKE LETT, GENERAL MANAGER — <br />When theprospective Contractor is unable to certify to any of the statements belo;v, it shall attach, an explanation to this Af <br />.fidavit. <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 />STATE OF �INDIANA <br />) SS: <br />BOONE COtJNTY <br />The undersigned Contractor, being duly sworn upon his/her/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 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 reftain 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 tiling 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 fi-orn patticipation in this transaction by any Federal <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 />Ver. 2 — March 2018 <br />