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CITY OF SOUTH BEND, INDIANA <br />QUOTEFOR SALE OR LEASE OF MATERIALS <br />AND NON-COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />QUOTENAME 120-0072020 Lamppost Program <br />April 14, 2020 at 9:30am Local Timesee Instructions to Bidders for electronic bid <br />FOR QUOTES DUE submission information <br />April 3rd, 2020 <br />Date:Firm:Gama Sonic USA Solar Lighting, Inc. <br />6185 Jimmy Carter Blvd, Suite F <br />Address: <br />(727-688-5030 please use this #) <br />Norcross, GA. 30071 <br />678-736-8303 x 104 <br />City/State/Zip:Telephone Number:() <br />Matt Cohen- Director, Commercial Sales <br />Agent of Firm(if Applicable): <br />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, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN,EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENTAND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />Georgia <br />STATE OF ___________) <br />) SS: <br />Gwinnett <br />COUNTY) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />1.Contractorhas 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 induceanyone 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. Contractorfurther says that no person or persons, firms, 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 />2.Contractorcertifies by submission of this proposal that neither contractor norany <br />ofits principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction byany 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 />Version 802/25/14 <br /> <br />