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CITY OF SOUTH BEND INDIANA <br />11A111 <br />OR <br />51� 'LEASE OF MATERIALS <br />SELLER'S QUOTE FSALE . . . . . . . . . . <br />AND NOWCOLLUSIONAND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />South Bend Police Department 701_#�­S' ample St. — Fencing Gates East & West Rear of <br />#-,UOTE NAME 6uildino.— <br />FOR QUOTES DUE, _,��embq#r <br />Diate: Firm: <br />Address: <br />aty/state/Ziv. <br />Imp 111111111 <br />w <br />slat, omen <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />ON R EGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />CERTIFICATIMITMENT AND <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COM i <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS; OR FOUNDRY <br />PRODUCTS <br />d-fix lease type or print) <br />_2JJL'*U'uJ'rA_m�4 2P <br />STATE CIF —PLI <br />SS: <br />c r\ COUNTY <br />The undersigned Contractor, being duly sworn, upon hi <br />that: <br />1 . Contractor has not, nor has any o) <br />company, corporation or partnership res <br />collusion or agreement with any person <br />letting nor to prevent any person from <br />bidding, and that this bid is made with <br />agreement, understanding or combinati <br />bidding. Contractor further says that no ll <br />account of such sale; and <br />oath, affirins under the penalties of perjury <br />e: <br />o wr agent of tb i fit7ZV <br />�,tnted -by him, entered into ally combination, <br />L _aD�Lone at such <br />0ing nor to induce anyonc Lo rcfrain from <br />reference to any other bid and without any <br />with any other person in reference to such. <br />I <br />ooration has ha <br />A�ve <br />AIJ&Ls s,. irms or crpi <br />N 0'1 1. <br />7'��Ingu11.1tim-01011 <br />2. Contractor certifies by submission I f this proposal that neither contractor nor any <br />'0 <br />of its principals are presently debarred, i suspended, proposed for debarment, declare-#! <br />ineligible, or voluntarily excluded from participation in this transaction by any federal <br />de artment or agency; and <br />p <br />3. Contractor has not, nor has any <br />investment activities in Iran. <br />to, nor an affiliate of, Contractor, engaged in <br />Version 8 — 02/25/14 <br />