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When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit. <br />NON-COLLUSIONANDNON-DEBARMENT AFFIDAVIT,CERTIFICATION <br />REGARDING INVESTMENT WITH IRAN,EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMMITMENTAND CERTIFICATION OF USE OF UNITED STATES <br />STEEL PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <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 that: <br />1.Contractorhas not, nor has any other member, representative, or agent of the firm, company, <br />corporation or partnership represented by him, entered into any combination, collusion or agreement <br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person <br />from bidding nor to induceanyone to refrain from bidding, and that this bid is made without <br />reference to any other bid and without any agreement, understanding or combination with any other <br />person in reference to such bidding. Contractorfurther says that no person or persons, firms, or <br />corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission or thing <br />of value on account of such sale; and <br />2.Contractorcertifies by submission of this proposal that neither contractor nor any of its <br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or <br />voluntarily excluded from 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 investment <br />activities in Iran. <br />a.gency or <br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from <br />time-to-time. <br />b.As provided by Ind. Code § 5-22-16.5-8, as amended from time-to-time, a Contractor is <br />engaged in investment activities in Iran if either: <br />i.Contractor, its successor or its affiliate, provides goods or services of twenty million <br />dollars ($20,000,000) or more in value in the energy sector of Iran; or <br />ii.Contractor, its successor or its affiliate, is a financial institution that extends twenty <br />million dollars ($20,000,000) or more in credit to another person for forty-five (45) <br />days or more, if that person will (i) use the credit to provides goods and services in the <br />energy sector in Iran; and (ii) at the time the financial institution extends credit, is a <br />person identified on list published by the Indiana Department of Administration. <br />4.Contractordoes not knowingly employ or contract with an unauthorized alien, nor retain any <br />employee or contract with a person that the Contractor subsequently learns is an unauthorized alien. <br />Version 4/2/2019Page -12Public Works Quote <br /> <br />