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{Yuen the prospective Contractor is unable to certify to mry of tine stutearents below, it slim! attach au er J
<br />CC}lV'I"I rC l`Or "Si NON-COLLV ION AND NON ICI 11 ,1�i�Il"1" �tl 1 I17 l 4Pl°lCERTIFICATION
<br />p anatinn to this rf�flrrlrrvi�
<br />REGARDINGIN I ,NT �'��� ����� C�;I "III^If" TI%� ;
<br />DISCRIMI ATIO COMMITMENTA (l lt�"'I'°Ih„f A�["IOC f:',1'G�
<br />IOID'IIsII" 'Yf dtlPl'f� �4I"rO, NON-
<br />NI)
<br />OR FOUNDRY PIt01)U C OF UNITED It STATES STEEL
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF Indiana )
<br />St. Joseph ) Ss:
<br />- p _.,_„_ COUNTY )
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms
<br />tender the penalties that:
<br />p es of perjury
<br />1. Contractor has not, nor has any other menibcr, rtpreseimtrrirve, or a fwerrt of ilae* hramm corn ,
<br />corporation el partnership represented by eerier„ era.tes°ed hitaa away caamtaNrmsauon„ cotlttwioam C'ai° agreement with
<br />aiay persona aclartiva to the pricc to be bid by araysirme at siscla Jetting, to On, cit an pi ray,
<br />i�aarr to induce anyone t o retrtadn trorn tarciclNarg� isrrd tlmsit idids bid is irmssd rvtidrerut refa,serly to array other bid in
<br />arrithotit stay agreement, arnaleawk,�aOinh Or Combination With any otlm�er pcarcari in reel �r�e toasuetpirbi bid
<br />Contectly, to re gays that aica persorr carper catas, firms, or corlauraticarr liner„, have or w»iid reeeive direct cI
<br />rirctrr°eswtly, any aebate, fen,:„ gi armg.
<br />i gift, c'aamm�rission or thing of valgac osm aceoipnt aaf staela salc; and directly or
<br />?. Caantractaac certifies by sisboamissicara of this Iaaaaposrrt that neither aorrti°actor nor any of its .rrirac"�
<br />OrePresently dehimimred„ sas pcsadert, Proposed for ala.baamaaerrt, dotd„rrccl irredrt„itmlem, or voluntarily excli1 1) fi rm
<br />pa�nieslataticart m this to a, SUaction by tiny hamdei°lid department air agency- l atolls
<br />-and
<br />in3.
<br />Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged
<br />inContractor
<br />activities in Iran.
<br />in
<br />a. harr-Iatitposa:S of this Cerlification, „",)ran"' irre,irns iliha government of Iran and any ag,ertc
<br />or instrunie,ntality of Iran, or as ot2merwrsc detat Ind. Code
<br />anaerrded frown tinrc-tt time° y
<br />as
<br />b, As provided by Ind. Code § 5-22-16.5-8, as anmeatded from time -to -time, a Contractor
<br />is engaged in investment activities in Iran if eitlmei-;
<br />i• Ccantraactor', its successor or its affilitat
<br />Million dollars ($2l),fl t1,00em Provides goods car, services oft ertty
<br />or 0) or more it, vayltte in the energy sec(a)r oflralri
<br />ii. Contractor, its successor or its aft7iliate, is a frraarrcizrl itmistitution that extends
<br />twenty iamilpiott dollars ( 10X)i) , f1()) Ol"11017c ill credit to another person for
<br />fortys an( let) days cmr snore„ if tkmat person ww°ild fir) use the credit to provides
<br />goods raiacl services ill, the. eraci�gw secta�t rim �Irrrrm, namd (ii) ;at the tune time
<br />financial institratiora extends credit, is a pel.sota identified on list published by
<br />the Indhina l)cpaJ'trmaerat of�ldrninistratiotm.
<br />Version 10/1712017
<br />Contractor's Bid for Public Works - 4
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