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When the prot "Ise dispe 0ontrorefor is tineible io cetyU)P to elly of The statentenis be/o is,, it shall aflach an explanatioss to this 417hlm,it. <br />MRAIN K 111] W312 M OEM I I It &MIRFRO I 9RIOB IJ DO Mmiky) I DION MR W W IM71,01LIJ <br />STATE OF Indiana <br />Elkhart <br />. COUNTY )SS" <br />.......... . <br />The undersigned Contractor, being 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 />companV, corporation or I artnershi i reiresented 6 him, entered into an i ioaWwlim- collusi*-F. <br />any person from bidding nor to induce anyone to refrain fiom bidding, and that this bid is made <br />without reference to anij other bid and without anVA agreement, understanding <br />any other person in reference to such bidding. Contractor further says that no person or persons, <br />tl <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 nor any of its <br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or <br />a. For purposes of this Certification, "Iran" means the government of Iran and any agency oi <br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from <br />time -to -time. <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 [ran; or <br />ii. 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, if that 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 />4. 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 an 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 />