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When theprospective Contractor is unable to certify to any of the statenwnts below, itshall attach an explanation to this Affida pit
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION
<br />RE GARDING INVEnMENT WITHIRAN,EMPLOYMENT ELIGIMLETY VERIFICATION, NON-
<br />DISCRIMINATION COMMITMENT 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 Illndilaina
<br />) SS:
<br />St, JOSeP,�, COLYNTY
<br />___ . . . .......................
<br />Tbe undersigned Contractor, being duly sworn upon his/fier/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 finn, company,
<br />corporation. or partnership represented by hini, entered into any combination, collusion or agreement with
<br />any pet -son relative to the price to be bid by anyone at such letting nor to prevent any person from bidding
<br />nor to induce anyone to refrain from bidding, and that this bid is made without reference to any other bid and
<br />without any agreernent, understanding or combination with any other person in reference to such bidding.
<br />Contractor further says that no person or persons, firms, or corporation has, have or will receive directly or
<br />indirectly, any rebate, fee, gift, commission or thing of value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor arny. of its principals
<br />are presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded fioni
<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 govern ment of Iran and any agency
<br />or instrumentality of Iran., or as otherwise defined at Ind. Code § 5-2246.5-5, as
<br />amended ftom time -to. -time..
<br />b. As provided by Ind. Code § 5-22-.16.5-8, as ainendedfirom three -to -brae, a Contractor
<br />is engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty
<br />million dollars ($20,000,000) or more in value in the energ
<br />.,y sector of Iran;
<br />or
<br />H. 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 />forty- Five (45) days or more, iftliat person will (i) us.e glee credit to provides
<br />goods and services in the, energy sector in Iran, and. (ii) at the time tile
<br />Financial institution extends credit, is a person identified on list published by
<br />tile Indiana Department of Administration,
<br />Version 01/2912020 Contractor's INd for IPuulbllic Works - 4
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