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CITY OF SOUTH BEND. INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />Water T r"tr"!jt Chemicals 2020-2024 <br />Mt 20?%, 9.30 AIMuI, Local Time <br />D�ate: Bidder <br />3-Al <br />(Firm): <br />Address: <br />City/State/Zip: <br />Aaj� Ielephone Number: <br />� <br />Agent of Bidder (if Apr1k 7all <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 quotes and bids. Please type or print) <br />2-, <br />COMMOt4WEALTH OF P NNSYLVANTA <br />STATE OF T <br />_JR— NOTARIAL S,EAL <br />Johnson, <br />5 a r Public <br />)SS- je,n Johnson Notary <br />y <br />B a e Tow n s h�p <br />eaver iownship <br />C r <br />COUNry �awfurd County <br />C C P i 05_03_2021 <br />My Commission EX ires 05-03-20121 <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />I « 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, finris, 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 />1 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 />a. For purposes of this Certification, "Iran" means, the government of Iran and any agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as <br />amended from time -to -time, <br />