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When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit
<br />.ff az
<br />CON RAC: TOICS NON-COI,I,LISION AND NON -DEBARMENT AFF1DA V11°, CERTIFIC'ATICDN
<br />REGARDING INVP',S 1'M�ENT 'ITH IAN, EMP1.OVMENI FL,IIG,v VERIFICATION,
<br />RIFIC TION, ION -
<br />DISC IMIN.ATION COMM ITMEN'I ANID C E1�" 1FICA 1 rON OF 11L,
<br />PRODUCTS OR FOUNDRY PrlODUC II OFU L�i'$SI"I"hD STATES STEEL
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF 11
<br />COUNTY SS:
<br />Tile undersigned , Contractor, being duly sworn upon his/her/its oathaffirms under the penalties ofperjur
<br />that: y
<br />1. Contractor has not, nor lr,rs any other iarerrrbe representative or argent of' the 11rrn, company,
<br />rxrrl rar<rtiora or frartareiship represented fly bill", entered into any col'llbin`tion,, c�:ollusicrrr or agreement will)
<br />Y 1 l taro farevent an arson
<br />any person relative to Ilre price to be lard by anycarac irr such letting taiir
<br />Mn. irr aarrlrrcc arryorrc irr arcfrarrr b riar Iyrdrlatag arrd that this bid is made witlroout rcftrenae�to spry catlrcr brelrar11
<br />without any agrcerrrent, understanding or coinhination with any other person in reference to such bidding.
<br />C,"ontr rctor lauthcr ^gays Chart no person or persons, firms, or corporGitarwn has, have or will receive directly a��ar
<br />indirectly, any rebate, fee„lib r crrnwurssion or° thing ofvalue oan �rlcc()Unt of such gale; rrn(f
<br />pare2� Contractor certrllcs by submission of Ibis proposal that ncithe r�� Contractor nor any of its lariracilrrrfs
<br />ipali l in Illrrieel srarlaerrde(l, proposed for debarrne�rrt, dccfa'ri°carf irrc�ligilrlc, or voluntarilyexcleacled ficrnr
<br />pr�trticrpal'iorr in tlir`s taarrsrrction by any Federal dcpartrnerrt <°d agcrary; arrel
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investmentactivities in Iran.
<br />a. I rrr ptii Doses Cal this Certification, `Iran,, paeans t:lie government of Iran and any agency
<br />oi• ii1str-trtrtentmrlily of Iran, or as rather isc deflrred at Ind. Code § 5-22-16. -5„ as
<br />datraended 1'ron'tinge-to-trine.
<br />b. As provided by Ind. ode § . , 2-16.5-8, as ararended from time -to -time, a Contractor
<br />is engagecl in investment activities in Iran if either:
<br />i• Contractor-, its successor or its arI'fiiliaatc, provides goods or se�r,vi�ce�s twenty
<br />or
<br />million dollars ($20,000,000) or tno,re ila vailue in the energy sector of Iran:
<br />twen
<br />ii. Contractor, its successor or its affiliate, is a Iinancial institution that extends
<br />IWen ty million dollars ($20,000,000) ot. more it) credit to anotherperson1<;rr
<br />frarty-irvc (45) (lays or' more, rl thal pe.rse�in will ere
<br />(il use tlrcredit to provides
<br />goods and services ill tiae er°rergy sector in Iran; and (ii) at the Orne the
<br />financial institution extends credit, is ar person identified on list pnblishcd by
<br />the Indiana I cpar~ttncnt ol'Administratiora.
<br />Version 4/2/2019 Contractor's Bid for Public Works - 4
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