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When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING
<br />INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, IKON', -DISCRIMINATION COMMITMENT
<br />AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be, completed for all quotes and bids. Please type or print)
<br />STATE OF _-L&dtgJ_U,
<br />ss:
<br />5J, IOCOUNTY
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that:
<br />1. Contractor has not, nor has any other member, representative, or agent of the firm, company,
<br />corporation or partnership represented by him, entered into any combination, collusion or agreement
<br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person from
<br />bidding nor to induce anyone to refrain from bidding, and that this bid is made without reference to any
<br />other bid and without any agreement, understanding or combination with any other person in
<br />reference to such bidding. Contractor further says that no person or persons, firms, or corporation has,
<br />have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account
<br />of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debarment, deciared ineligible, or
<br />voluntarily excluded from participation in this transaction by any Federal department or agency; and
<br />1 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 agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended
<br />from time-to-timie.
<br />As provided by Ind. Code § 5,-22-16.5-8, as amended from time -to -time, a Contractor is
<br />engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty million
<br />dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />ii. Contractor, its successor or its affiliate, is a financial inistiitutio,n that extends twenty
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />days or more, if that person will (j) use the credit to provides goods and services in
<br />the energy sector in Iran; and (fl) at the time the financial institution extends credit,
<br />is a person identified on list published by the Indiana Department of Administration.
<br />Non -Collusion Mon -Debarment Affidavit Non Iran Form 2016
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