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CITY OF SOUTH BEND INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />BID NAME Water Treatment Chemicals 2020-2021 <br />FOR BIDS DUE April 14, 2020, 9:30 AM, Local Time <br />r <br />/S:Cnm <br />1 <br />Agent of Bidder (if Applicable): <br />Bidder <br />(Firm): <br />When the prospective Contractor is unable to certt& 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 MAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />1. •1 ^1 ! . 1 . • 1 1 r .� 1. <br />STATE OF ` -, <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 • 1. representative, agent of <br />company, corporationor . 1 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. • . • no person or persons,or • • .tion has, have <br />accountor will receive directly or indirectly, any rebate, fee, gift, commission or thing of value on <br />1- and <br />2. Contractor certifies by s• ! of proposal th, • . •nor any <br />of principals presently debarred, suspended, proposed for debarment,declared <br />or • .' excluded from participation a . • by any Federal <br />department or g 1 <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,government of id any agency <br />1 instrumentality of or as otherwise defined a • Code <br />amended from time -to -time. <br />