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When the prospective Contiactor is unable to cedify to any oj'the statements below, it shall attach an explanation to this Affidavit.
<br />1.1 LIT." 10101 nPLIM 81 911110111110
<br />11 L 3 111,1113 1'L Lem 10L k I k wh, 1,
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<br />DOI F6 1 01
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF Indiana
<br />) SS:
<br />Allen
<br />COUNTY I
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury thav
<br />I , Contractor has not, nor has any other member, representative, or agent of the firrn,
<br />company, corporation or partnership represented by him, entered into any combination, collusion
<br />or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent
<br />any person from 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 agreement, 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 of value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debartnent, declared ineligible, or
<br />voluntarily excluded from participation in this transaction by any Federal department: or agency;
<br />and
<br />3, Contractor has not, nor has any successor to, nor an affiliate of, Contractor., engaged inl 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 amended from
<br />time -to -time.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -tine, 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�,00:0,000) 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 it)
<br />the energy sector in Iran; and (ii) at the tiine the financial institution extends credit, is
<br />a person identified on fist published by the Indiana Department of Achninistratioji.
<br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor retain
<br />any employee or contract with a person that the Contractor subsequently learns is aril unauthorized
<br />Version 2/14/2020 Page - 3 Public Works Quote
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