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When the prospective Contractor is unable to cent fy to any of the statements below, it shall attach an a planotion to llrrs Affldavit
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT,
<br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY
<br />VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE
<br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />V
<br />STATE OF
<br />SS:
<br />COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of peijury that;
<br />I. Contractor has not, nor has any other member, representative, or agent of the firm,
<br />company, corporation or prtnership represented by him, entered into any combination, collusion
<br />or agreement with any person relative to ti,ic price to be hid by anyone fit such letting note to
<br />prevent tiny person frown bidding nor to induce anyone to refrain li`t,m lidding, and that this bid
<br />is trade witltotit reference to any other bid and without any agreement, understanding or
<br />combination with any other person in reference to such bidding. Contractor further says that no
<br />person or persons, firms, or corporation has, have or will receive directly or indirectly, any
<br />rebate, fee, gift, commission 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
<br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or
<br />voluntarily exclude(] 1'rom. participation in this transaction by any Federal department or agency;
<br />and
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor,, engaged in
<br />investment activities in Tran.
<br />a. For purposes of this Certification, "Iran" means the government of Iran and any agency or
<br />instrumentality of Tran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from
<br />titne-to-time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended fi•oni tithe -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 f"rnancial institution that extends twenty
<br />million dollars ($20,000,000) or more in ei,edit to another person for forty-five (4 )
<br />days or more, if that Iaerson will (i) use the credit to provides goods and services in
<br />Non -Collusion Nun-Debmimit Affidavit Non ]ran Pbrni
<br />
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