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When the prospective Contractor is unable to cerfify to any of'thestatemeniv below, it shall attach an exlVanation to this Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON. -DEBARMENT AFFIDAVIT, CERTIFICATION
<br />REIZD.ING.1l.NV.ESTM.E.NI'W.1'.IPH A , EMPLOYMENTELIGIBILITY VERIFICATION, NON. -
<br />DISCRIMINATION COMMITMENT AND CERTIFICAIPION OF USE OF UNIlTED s,rA,rES sTEEL
<br />PIM)DUCTS OR FOUNDRY PRODuCTS
<br />(Must be completed for all quotes and bids., Please type or print)
<br />STATE 0-11�' liriid�a1n11@_,_
<br />) SS::
<br />5tJP§QP COUNTY
<br />The undersigned Contractor, being duly sworn upon his/pier/its oatli, affirms under the penalties of perju.ty
<br />that:
<br />I . Contractor has not, nor has any other member, represeniative, or agent of the firm, company,
<br />corporation or partnership represented by him, entered into an.y combination, collusion or agreement with
<br />,any person relative to the price to be bid by anyoneat such letting nor to prevent any person from bidding
<br />nor to induce anyone to refrain frorn 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 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 />1 Contractor certifies by submission of this proposal Chair 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 opt., Contractor, engaged in
<br />investment activities in Iran,
<br />a. For purposes ofthis Certification, "Iran" means the government of Iran and any agency
<br />or instrurnentality of Iran, or as otherwise defined at Ind., Code § 5-22-16.5-5, as
<br />amended From time -to -time.
<br />b. As provided lby Ind. Code § 5-22-16.5-8, as amended from, time-to-thrie, a Contractor
<br />is engaged. in investment activities hilrari, if either:
<br />L Contractor, its successor or its affiliate, pnrorvides goods or services of twenty
<br />million dollars ($20,000,000) or more in value in the energy sector of Iran;
<br />or
<br />iL Contractor, its successor or its affiliate, is a financial institution that extends
<br />twenty rnillion dollars ($20,000,000) or more in credit to another person for
<br />forty-five (45) days or more, if that person will (i) use the credit to provides
<br />goods and services in the energy sector in Iran; and (pp) at the time the
<br />financial institution extends credit, is a person identiried. on list published. lby
<br />the Indiana Department of Administration.
<br />Version 0,1129/2020 Contractor's Bid for Pubk Works - 4
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