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lYlrex the pPovectiye coldraefor is anable to c4'r11f � to atrp of Nre statements 6elrrly, it slrrrll rrllrrelr nn c-AIrlrrrrrrlinrr to this fi ffrdayh. <br />CONTRACTOR'S NON -COLLUSION AND NON-DEBARIVIENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMNIITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL <br />PRODUCTS OR FOUNDRY PRODUCTS <br />(tvinst be completed For all quotes and bids. Please type or print) <br />STATE OF lND[ANA ) <br />ST,JOSEPH COUNT ) SS:Y ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />1. Colltractol- has not, nor has any other member, representative, or agent of the firth, company, <br />corporation or partnership represented by liim, entered into any combination, collusion or agreement with <br />any person relative to the price to be bid by anyone at such letting nor to prevent any person from bidding <br />nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and <br />without any agreement, understanding or combination with any other person in reference to such bidding. <br />Contractor further says that no person or persoils, firths, or corporation has, have or will receive directly or <br />indirectly, any rebate, fee, gift, cotllllliss1011 Or thing Of Value on account of such sale; and <br />2. Contractor certifies by submission of this proposal that Neither contractor nor any of its principals <br />are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded fi•orn <br />participation in this transaction by any Federal 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 ptn•poses ofthis Certification, "Iran" means tale government of Iran and any agency <br />or instrumentality of ]ran, or as otherwise defined at Itld. Code § 5-22--16.5-5, as <br />amended from time -to -tinge. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended froln tune -to -tine, a Contractor <br />is engaged in investment activities in Iran if either: <br />Contractor, its successor or its affiliate, provides goods or services of twenty <br />million dollars ($20,000,000) or more in value in the energy sector of Iran; <br />or <br />ii. Contractor, its successor or its affiliate, is a financial institution that extends <br />twenty million dollars ($20,000,000) or more in credit to another person for <br />Forty-five (45) days or more, if that person will (i) use the credit to provides <br />goods and services in the energy sector in Iran; and (ii) at the time the <br />financial institution extends credit, is a person identified oil list published by <br />the Indiana Department of Administration. <br />Version 7/2012018 Contractor's laid for Public Works - 4 <br />