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"';6t1rffli ' . <br />CITY OF SOUTH BEND, INDIANA <br />!UOTE FOR SALE OR LEASE OF MATERIALS <br />FS1t� [ <br />_t1SlON AND NON DEBARMENT AFFIDAVIT ANDY. <br />r rj;'ii7.r: <br />r-'_ <br />RIMINATION COMMITMENT FOR SELLERS <br />Preventative Maintenance & Repalr HVAC Equipment and Controls -v <br />QUOTE.NAME South 13end UtllEtles 2010 <br />FOR QUOTES DUE June,12 2010 <br />©ate: June 11, 2018 Firm: Johnson Controls, Inc. <br />Address: 4312 N. "technology Drive <br />City/State/Zip: south Bend, IN 46628 Telephone Number: (574 ) 289-6336 <br />Agent of Firm (if Applicable): Brian Gilliand <br />11111ell 1h o pf'Uspeelke CV111melm, is unable 10 eerl f ,1a altj, of the slalesreals belotv, t1 shall allacll all erldallalfotl 10 1Gfs ttffldaVI1, <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERI'II' CATION REGARDING INVESTMENT WITH IRAN, E MPLOYME, NT <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. Plem type or print) <br />STATE OF Indiana <br />) SS: <br />St. ,Jospeh COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of peijury <br />that. <br />I . Contractor has not, nor ltas any other member, representative, or agent of the firill, <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 bidi 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 Berson or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on <br />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 hats not, nor has any successor to, nor all affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />Version 3 — 02/25/14 <br />