|
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-DEBARIIVIENT AFFIDAVIT, CERTIFICATION
<br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON-
<br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL
<br />PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF )
<br />) SS;
<br />1MY/I.... , COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury
<br />that:
<br />1, Contractor has not, nor has any other member, rc,prescntativcP, or agent of the firm, corn any,
<br />corporation oar partnership represented by hirer, entered into any combination, collusion or a,greerncrtt wvith
<br />any person relative to llic price to be bid by anyone to suet, letting nor toprevent any person frorn'bidding
<br />nor to induce anyolle to refrain from bidding, and that this boat is made without reference to any other laid and
<br />without any agraernent, understanding or Combination with arty otlter person in reference to such bidding.
<br />Contractor furtiler says that no person or persons, firms, or corporation has, have or will receive directly or
<br />indireedy, any rebate, fee, gilt, earn mission or tl,io,g Of value on account of such sale; ,nad
<br />2, Contractoa certifies by submission of this proposal that neither contractor nor any of its principals
<br />rare presently debarred, suspcnded, proposed for debarment„ dochared ineligible, or voluntarily excluded frorn
<br />participation ill this transaction by ally Federal departtrlent oragency; 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 all'll,is Certi fication, "Iran" nlerans the government of Iran and any agency
<br />or instrumentality of Iran, or as othemvise defined at Ind. Code § 5-22-16.5-5, as
<br />amended from tinge-to-tit,rte.
<br />b. As provided by Ind Code § 5-22-16.5-8, as amended from time -to -time, a Contractor
<br />is engaged in investnicrit activities in Iran ifcither.
<br />Contractor, its successor or its aff Bate, provides goods or services of twenty
<br />million dollars (; 20,000,000) or snore in value in the energy sector of Irian
<br />or
<br />ii. Contractor, its successor or its affiliate, is a Iinarttaal tnstitutton th�,al extends
<br />twenty million dollars ($20,000,000) or nrrore in era;alit to another person for
<br />forty-five (45) days or more, if that person will (i) use the credit to provicde.1
<br />goods and services in the energy sector in lean; and (ii) at the tinne the
<br />financial institution extends credit, is a person identified ors list published by
<br />the Indiana Department of Adrninistration.
<br />Version 7/20/2018 Contractor's Bid for Public Works - 5
<br />
|