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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 />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH II AN', EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISC.RIMINATION COMMI"l"MEN"l" AND CERTIFICATION OF USE OF UNITED STATES STEEL, <br />PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF MICHIGAN ) <br />) SS: <br />—BERRI M_._ COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />1. Contractors has not, nor limn any other mernber, representative, or agent ofthe ffrin, company, <br />corporation or partnership represented by him., entered into any combination, collusion or agreement with <br />any person relative to (lie price it) be bid by anyone at such letting,tor to prevent any person from bidding <br />nor tc;^) induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and <br />without any agreement, understanding or combination with any other person in reference to such bidding, <br />Contractor tiwilicr says that no parson or persons, farms, or corporation has, have or will receive directly or <br />indirectly, any rebate, fee, gitl„ commission or thing of value on accoulmt ofsuell sale; and <br />2. Contractor certifies by srabmission of this proposal that neither contractor nor any of its principals <br />are presently debarred, suspended„ proposed for debarment, declared ineligible, or voluntarily excluded from <br />participation in this transaction by any Federal department or agency; and <br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and any agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as <br />amended Irons time-to-tinie. <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 either: <br />Contractor, its ;;ucaessor or its affiliate, provides goods or services of twenty <br />million dollars ( 20,000,000) or morc in value in the energy sector of Iran; <br />or <br />ii. Contractor, its successor or its affiliate, is a financial institution that extends <br />twenty million dollars (20,000,000) or more in credit to another person for <br />Marty -five (415) days or more, if that person will (i) use the credit to provides <br />goods and services in the energy sector in Iran; and (ii) at the time the <br />financial institution extends credit., is a person identified on list published by <br />the Indiana Departntent of Administration. <br />Version 10/17/2017 Contractor's Bid for Public Works - 4 <br />