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CITY OF sou'rH BEND, INDIANA
<br />t7
<br />SELLER'S BID FOR SALE OR LEASE OF MATEMALS
<br />WD NAME Water Treatvaunt ChernicaLs 20,20 2021
<br />--- FOR
<br />-------
<br />- --- --- ---- -- - ------- ------------------------------------- -------------------- ----- ---------- - BW DUE Aprii 14,20201,9:30 AM, Local Time
<br />Bildcler
<br />Date: 13 Apnl 2020 Prrn)� Watcon, H,)c,
<br />Addre,sc,v 2215 SOUth Ma�inStreet
<br />.. .... .. . .......... ... ..... . .. . . . ...... ... . . . ... . . ... . . ............. . . .. .. ......................... . . ..... . . ..... . ........... . .......... .. . ............. . . . . . ... . . . ................ . . . .. ........ ......... . ........... . ........ I ... ....... . . - ------- --
<br />City/State/Zip� SOUth Bend, IN 46613 1"Oephone Number (15j) 287-1'3397
<br />A,gent of dder (ff Apphcable).
<br />Iflien the prempeedve Coxnlractor is unable fo cerrffy to an , o 'the hehmv, it shall atlach apt twplanation to this l7a1mavft
<br />("'ONTRACUOR'S NON-0 ' HAXSION AND NON -DEBARMENT AFFIDAVIT'
<br />Cl EWFIFICATJON REGARDING INVESTMENTW111-1 IRAN, EMPI..,0VMF,NT
<br />ElA(JBlJ..J`l`Y VER]FIC"ATION, NON-DISCRIMINA110N COMNIFTMENT AND
<br />C.ElITIFICATION OF USE OF UNrm) STA"YES, s,rEEL P1 ODUCTS OR FOUNDRV
<br />PRODIJCIT'S
<br />(MUSt be cojnpleled fl-brall quolesand bi(,Js. Hcasc type or prinl,)
<br />S'TAFF ()F pnd'HlllrNll
<br />)SS -
<br />COUNTY
<br />flic undcrsigned Conlracmr, bcng (110Y Sworn urm�,llll his/hcr/its oath,affirms guider the penalfies of par
<br />10 C(-nitractor has not, nor has; any odwr tnenfl-,wr, repre,",enlawvc. oragent of" the firim,
<br />corripany, corploraW,)n or Partnership irepresentcd by Nryi, cntcred into any c(..)rnbinahon.,
<br />Collusion M lvlh ,iny person r(dative to Ific priceto be, hid by anyonle, at such
<br />letflng nor to prevent an ' v 1".)crson ftcitn hiddirkg nfor to induce cui.yonlc", w r&'rain n fr()i
<br />biddiiig, and deal this bid i'S RUA& WithOL11 I'deNTICe w ziny other bid ,and With(WI rffl�
<br />(, � 11 1 Id)
<br />"'lgreenlent" unciclsuinding, or wilh a,nv wher 1.,)erson in rd',reCC 0 SM
<br />hiddirlp". Ccmtractor l'urther says Ilia[ no person or persons, alrnis, or corpor,,ition has, hzivr("
<br />or wdl rccek,re or indi]TCdy, any rebate., fee, gifi, corninission or thing ol'valuc on
<br />aCCOW11 Of SUCII 4C ' and
<br />2. Contr,actor ccrtifics by subrr�issioii ofd-ds propc)sal fl,uat rj,61hcr contractor nor any
<br />M' ii[s principals are presently debarred, SLISPeTlCled, debannera, declared
<br />irieligible, or voluntardy CNCfudcd froiil J-),articipafion in this muisaction by any l'olcnd
<br />del,'mro-nent 4,'n agency., and
<br />3. Comractor has nol, nor has any snccessov to, nc)r worn afflh ate of., Contracwr, cnt.;agCd rn
<br />invesiment acflvi0es in Iran.
<br />Rau` fflstrurnentalnt ' v of Irari., (w as othcrwke defined at Ind, Code § 5-22-W5-5, as
<br />amended fron'i hinc-to-finle.
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