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When theprospective Contractor is unable to certify to any of the Statements below, it Shall attach an explanation to Illi'T Affidalfil,
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION
<br />REGARDING INVESTMENT wrai I I�AN, t,MPLOYMENTELIGI ELIGIBILITY VERIFICATION, NOC N-
<br />I I" SI,
<br />DISCIUMINATION COMMITMENT AND CER7,11,1CA"F ON 0 V, , 01; UNITED STATES STEEL
<br />PRODUCTS OR FOUNDRY PRODUCI-S
<br />(Must be completed for all quotes and bids, Please type or print)
<br />STATE OF Indiana
<br />St. Joseph SS:
<br />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, ret)resenlafive, Or Agerit Of the firr1j, colylparly,
<br />corporation or Partnership represented by him, entered inin any coilibirlation, collilsk"I 0I, agreonlent with
<br />any person relative to the Price to be bid by anyone at stich icallig nor to ),.even, arty person fr('),11 hiK i
<br />-Da', bidding, and that this bid is madc willjout refcrellce to ,,try other bid and
<br />nor to induce anyoric to refTail,' fi id ng
<br />WithOtil ally agreeiriou, understanding or combination with a"Y Other person in reference to such bidding,
<br />Contractor further says that n4) person Or pers(nis, firms, Or corporation has, have or will receive directly or
<br />indirectly,, ony rebate, 11", gin, commission or thing of vkilric on account ofsuch :wade; 4,111d
<br />1 Contractor certifies by submission Of this PrOPOsal that neither contractor nor any of its priacil)DIS
<br />are presently debarred, susperided, proposed for debarment, declared ineligible, Or voluntarily excluded fiont
<br />participation in this transaction by any Federal department or agency; and
<br />3. Contractor has riot, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investment activities in Iran. 0
<br />a. F"Or PurPoses Of this Certification, "Iran" mWans the government of Iran and any agency
<br />or i nstill menta I i ty of' Iran, or as otherwise del nett at Ind, Code § 5-22-16.5-5, as
<br />amended ftOill time -to -tinge.
<br />b. As provided by Ind. Code § 5-22-16,5.8, as amended from time -to -time, a Contractor
<br />is engaged in investment activities in Iran if citfici%
<br />i. Contractor, its successor or its affiliatc, provides goods or services of twenty
<br />million dollars ($20,000,000) or more in, value in the energy sector of Iran;
<br />oil
<br />It Contractor, its successor or it's al'f`il';'Ilc, is a financial insfiftlti0l) that exten(N
<br />twenty million dollars ($20,000,000) or more in credit to another person for
<br />forty-five (45) days Or More, if that person will (j) use the credit to provides
<br />goods and selTices ill the energy sector in [ran; and (ii)i at tile tirne the
<br />financial institution extends credit, is zr person iderijifled on list Published by
<br />the Indiana Departnient of .dministration.
<br />Version 4/2/2019 Contractor's Bid for Public Works - 4
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