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y"i <br />CITY" OF SOUTH BEND. INDIANA �P <br />SELLER'S BIE) FORSALE OR LEASE O.F.-MATERIALS Y� <br />AND NON-COLLUSI''ON AND PwN0,N DEBARMENT AFFIDAVIT AND A65 m <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />BID NAME Venues Parks & Arts 2020 Chemicalpypply <br />FOR BIDS DUE Janua 101 2020 9:30 am _ <br />Bidder <br />Date: 1/10/2020 _LL.. (Firm): Mark Farm,§qRp1y.1nc <br />Address: 3135 Orane�Rd <br />_......... <br />�...�._.... ._._ . <br />City/State/Zip: Niles, MI 491_20 ._..Telephone Number: ^ -059869683 <br />_ <br />Agent of Bidder (if Applicable): <br />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, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF14Ais <br />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, representative, or agent of the fine, <br />company, corporation or partnership represented by him, entered into any combination, <br />collusion or agreement with any person relative to the price to be bid by anyone at such <br />letting nor to prevent any person from bidding nor to induce anyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />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 />