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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />BID NAME Sp�ec S — One (1) or More 2018 or Newer Enner <br />FOR BIDS DUE Auq ust 28, 2018 at 9:30 a.m. <br />, Medical Vehicle <br />I T ki <br />PKACF, <br />Bidder <br />Date: -�vtt (Firm): C czc <br />Address: qel <br />City/State/Zip: Tel'ephone Number: <br />Agent of Bidder (if Appkable): N /,A- <br />Wh en th e prosp ective Con Ira eto r is an able to certify to any of th e statemen Is belo w, it sh a 11 attach an exp Ion ation to th is Affida vit, <br />1WRIZZ1111119030 1111110KNO <br />oil A <br />A <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF 1�;`N3"N"NA <br />) SS: <br />COUNTY <br />The undersigned Contractor, being duly swom upon bis/ber/its oath, affirms under th�e penalties of perjury <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, firims, 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 affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and any <br />agency or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, <br />as amended from time -to -time, <br />K <br />