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When the prospective Contractor is enable to certify to any of the statements below, it shall attach an explanation to this AIJidavil. <br />1�''. ; <br />(iVlust be completed for all quotes and bids. Please type or print) <br />STATE OF I MICHIGAN ) <br />) SS: <br />BERR I EN COUNTY <br />Fhe undersigned Contractor, bein- duly sworn upon his/her/its oath, affirms under the penalties of perjury 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. collusion <br />or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent <br />any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made <br />Without reference to any other bid and without any agreement, understanding or combination with <br />any other person in reference to such bidding. Contractor further says that no person or persons, <br />Firms, or corporation has, have or will receive directly or indirectly, any rebate. fee. gift. <br />commission or thing of value on account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor not, any of its <br />principals are presently debarred, suspended; proposed for debarment, declared ineligible, or <br />voluntarily excluded from 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 investment <br />activities in Iran. <br />ar For purposes of this Certification, -.Iran-" means the govemnlent of Iran and an% agency or <br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5a as amended frorn <br />tulle -to -time. <br />b. As provided b� hid. Code § 5-22-16.5-83 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: of - <br />Contractor, its successor or its affiliate, is a financial institution that extends twenty <br />million dollars ($20,000,000) or more in credit to another person for forty-five (45) <br />days or more. ifthat person will (i) use the credit to provides goods and services in <br />the energy sector in Iran; and (ii) at the time the financial institution extends credit. is <br />a person identified on list published by the Indiana Department of Administration. <br />d. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain <br />any employee or contract with a person that the Contractor subsequently learns is all unauthorized <br />alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of all of <br />Version 4/2/2019 Page - 8 Public Works Quote <br />