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When theprospective (Ionivactor is wrable to cerly.j„ to any of the statements below, it shall athich air e.Tlallayion to this ziffielavit,
<br />CONTRACTOR'S NON -COLLUSION AND NON-DEBARMENTAFFIDAVIT, CE WHFICATION
<br />REGARDING INVESTTNT WITH HULN, EMPLOYMENTRAGIBILITY �TRIFICATION, NON-
<br />DISCRIMINATION COMMITINIE"NT AND CERTIM"W1.10N OF USE OF UNITED STATES STEE'L.,
<br />PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must Inc Completed for all quotes and bids. Please type or print)
<br />STA"ITEOF lndiana
<br />St. Joseph COUN'ry SS:
<br />The undersigned Contractor, being duly Mom Upon his/her/its oath, affirins under the penalties of pedLiry
<br />that.
<br />-
<br />I I. Contractor has not, nor has any other member, reprewn tali ve, or agent of the firm, coojpajjry,
<br />corporation or partnership represented by Kira, entered intoany cornbination, coltusion or agreement with
<br />any person relative to the price to be bid by anyone at such letting nor to prevent any person Irani biddin"
<br />g
<br />nor to induce anyone to refrain from bidding, and that this bid is made without reference to any otherbid alicI
<br />without any agteenient, Understanding or cornbination with any other person it, 1-cf6-ence to such biddin&
<br />Contractor further says that no person or persons, ['inns, or coqiorafion has, have or Will receive directly Or
<br />in(firectly, any rebate, fee, gift, coniniission or thing of value on acconnt of slich sale; and
<br />I Contractor certifies by submission of this PTOPOSa[ that neither contractor nor any of its prfficipals
<br />are presently debarred, suspendcd, proposed finer deharment, declared nicligibk, or voluntarily excluded fi arn
<br />participation in this transaeflon by any Federal department or agency; and
<br />1 Contractor has nut, nor has any wccessor to, nor an affiliate of, Contractor, engaged in
<br />investment activities in Iran,
<br />For purposes ofthis Certification, "Iran" mcans the governnient offi-tan and any agcncy
<br />or instrumentality of Iran, or as otheavise defined at Ind, Code § 5-22-16,5-5, as
<br />arnended frorn tiruc-to-linie,
<br />b. As previded by Ind. Code § 5-22-16,5-8, as amended froni bane-to-firne, a Contractor
<br />is engaged in investment activities in ]ran if either:
<br />Contractor, its Successor or its affiliate, provides goods or services of twenty
<br />million dollars ($20,0I00,000) or rnore in value in the energy sector OfIran;
<br />or
<br />Contractor, its SUCCCSS01- or its affiliate, is a financial institution that extends
<br />twenty rnillion dollars ($20,000,000) or inore in credit to another person 1,0y
<br />foi-ty-five (45) days or more, if that person will (i) use the credit to provides
<br />goods and services in the energy sector in Iran; and (d at the tinle the
<br />financial institution extends credit, is a person idcutified on list PUbliglied by,
<br />the Indiana Departryient otAdministration,
<br />Version 402019 Contractor's ffid for Public Works - 4
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