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BID NAME <br />FOR BIDS DUE <br />Date: <br />Address <br />CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />U - One (1) or More 2018 or Newer Compact Track Loader <br />September 25. 2018 at, 9:30 a.m. <br />Bidder <br />9/19/2018 (Firm,): <br />28747 OLD US 33 WEST <br />HULL LIFT TRUCK INC. <br />City/State/Zip: ELKHART, IN 46516 Telephone Number: (574) 293- 8651 <br />Agent of Bidder (if Applicable): MIKE GRIFFY <br />When the prospective Contractor is unable to certify to any of floe statements beloiv, it shall attach an explanation to this Affidavit. <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 />ELKHART COUNTY ) <br />The undersigned Contractor, being duly Sworn Upon his/her/its oath, affirms under the penalties of pejury <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, firms, 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 />2 <br />