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QUOTE NAME <br />FOR QUOTES DUE <br />CITE' OF SOUTH BEND INDIANA <br />SELLER'S QUOTE FOR SALE OR LEASE OF MATERIALS' <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />South Bend Police Department 701 W. Sample St. - Boiler Purchase (Mecha <br />March 10, 2020, 9:30 am local time <br />Date: March 10, 2020 Firm: Herrman & Goetz <br />Address: 225 S. Lafayette Blvd. <br />City/State/Zip: South Bend, IN 46 601Telephone Number: 574) 282-2596 <br />Agent of Firm (if Applicable): _.19.1A. w...._wwwwww........ .............. _ ..._______.. <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 OF Tnda a, <br />SS: <br />S t -.._,Los..eh 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 firm, <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 <br />on 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 />Version 8 — 02/25/14 <br />