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" () UAW nr <br />7 <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 />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />BID NAME Janitorial Supplies 2018 <br />FOR BIDS DUE June 12, 201 8,_9:30, a.m., local time <br />Bidder <br />Date: (Firm <br />Address: <br />ry <br />City/State/Zip: -"Yelephone Number: 3 7 <br />Agent of Bidder (if ApplicE ble): <br />O'hen the prospective Contractor is unable to anexplanation tothisAffidavit <br />CONTRACTOR'S NON -COLLUSION AND NON -DE BARMENT AFFIDAVIT, <br />CERTIFICA'110N REGARDING INVESTMENT WITH IRAN, E MPLOYMENT <br />ELIGIBILITY VERIFICATION, NONN-DISCRIM1 NATION COMMITMENT AND <br />CEIITIFICATION 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 <br />SS: <br />COUNTY <br />The undersigned Contractor, being duly sworn upon his/hor/its oath, affirms undQr the ponatties of perjury <br />that: <br />I. Contract(,- has not, nor has any other member, representative, or agent of the firill, <br />cornpany, corporation or partnership represented by hini, entered into any cornbination, <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 fi-orn bidding nor to induce anyone to refrain fi-0111 <br />bidding, and that this bid is niade without reference toany 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, firins, or corporation has, have <br />or will receivd.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 Eire presently debarred, suspended, proposed for debarnient, 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 affiliate of, Contractor, engaged in <br />invcstment activities in Iran. <br />