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ff"hen the prospective Contractor is unable to cerdffir any t4'lhe statements belo;v, ;I shall attack an arlVanation to
<br />CONTRACTOR'S NON-COL1,11SION AND NON -DEBARMENT AFFIDAVIT,
<br />(""ERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMEN'r EIAGIBILITY
<br />VERIFICATION, N ON-D ISCRI MI NATION COMMITMENT AND CERTIFICATION OF USE
<br />OF" UNITED STATES STEEL, PRODUCTS OR FOLJNDRY PRODUCTS
<br />(Must he completed for all quotes and bids, Please type or print)
<br />STATE
<br />St. Joseph COUNTY SS:
<br />The undersigyned Contractor, bCiDg duly sworn upon his/her/its oath, affirm s under the penalties of peijury that:
<br />1. Contractor has not, nor has any other member, representative, or agent of the firrn,
<br />company, corporation or partnership represented by hinn, entered into any combination, collusion
<br />or agreement with any person relative to the price to be bid by anyone at such letting not- to prevent
<br />any person frorn bidding nor to induce anyone to refrain from bidding, and that this bid is made
<br />without reference to any other bid and without any agreernent, understanding or combination with
<br />any other person in reference to such bidding. Contractor further says that no person or persons,
<br />firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift,
<br />commission or thing ot'value on account of such sale; and
<br />1 Contractor certifies 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;
<br />and
<br />3, ("ontractor has not, nor has any successor to, nor an affiliate of; Contractor, engaged in investment
<br />activities in Iran.
<br />a. For purposes of this, Certification, "Iran" means the government of Iran and any agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16,5-5, as arnended from
<br />time; -tea -time.
<br />b. As provided by Ind, Code § 5-22-16.5-S, as amended froni urrie-to-time, a Contractor is
<br />engaged in investinent activities in tran ifeither:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty million
<br />dolkirs d S20,000,000) or more in value in the energy sector oflran, 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 lbrty-five (45)
<br />days or inore, if that person will (i) use the credit to provides goods and. services in
<br />the energy sector in Iran; and (ii) at the time the financial institution extends credit, is
<br />a person identified on list published by the Indiana Department of Administration.
<br />Version 2/14/2020 Page - 8 Public Works Quote
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