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CITY OF SOUTH BEND INL1IANA
<br />SELLER'S BID FOR SALE OR LEASE OF MATERIAL
<br />BID NAME Water Treatment Chemicals 2021-2022 _
<br />FOR BIDS DUE April 13, 2021, 9.00 AM, LocaI Time
<br />Date: 4: 12/2021
<br />Address: 5727 l ud a stria l load
<br />Bidder
<br />{ irnl}- Cht rwjcal Service Inc_
<br />city+l tatel7# Fort Wayrie, IN .40825 Telephone Numhr?r_ (260 ) 4464536
<br />Agent of Bidder {if Applicable): Tricks Kris«t�usi-k>rmntirl c fri c,}tt>t� roup_c rlxl
<br />fflu x lhd- Provpeclive Cirrrlrartrxr L re,rrrl;fe 141,1 c'erjiA' cn �JI �' rrj Jfir .eX#rrearrrlls hetaw, i1 shuf! attach an ['_tPideluainu fu this rI jfidfjry r,
<br />'COOT AC'TOR'S N0N-('I11,LU,S[ON AND NON-E)[?IiARME -i' A FFIDAVIT,
<br />CERTIFICATION REGARDING INVLS-1'MEN'1'WIT11 iRAN, EMPI.C3-VMENT
<br />ELIGIBILITY VERI1=i['ATiON, NON-DISC'Rin'>rINATION (:OMMITMENT AND
<br />C'ERTIFIC'ATION OF UST; OF 1 J N I T E D STATES STEE1, I'RO1)UUPS 0R F(}11N DRY
<br />PRODUCTS
<br />(M+ N-t be cornplcled fear .Ell gtiote,� kind bads. P1easL� Iypc or Taint)
<br />STAn of Indiana J
<br />} SS:
<br />Allen C'Ot;iNTY }
<br />T11C undrrxigned COW ractor, beiot duly',W(11-1l upon hip l)cri ii.-4 sk:rll1, ;l(filE- }% IIn[i('r tlIe p;�rtaItic-, of PCI jury
<br />that.
<br />I . COT] Li"r1Ct0F 11.1ti not, I]OI' 1],1S imy 0Lht;i' mil r her, representative., or aguit of tht firm.
<br />0011111all , corpuralioii use partnu,hip represenlcd by 11im, entered ij11ca ariy conibinatiorl,
<br />col lusion or ijgvixi11cr t w 1 E h alry person cc] ativLc to Elie pricc to he hid by anyone .It tins'
<br />Iciling nor to provent any pt trm)n from bidding nor to i n(ILIcc itll}ri1r1L' tO refrain IrOM
<br />bidding, wid 1hat this bid k made withow rcfl:rcncc to any clther bid alld Without ally
<br />aucement, undemtaodin�i or coanhination with any other pen un in rcfi rc: lcx; to such
<br />bidding_ Cont racIor further says that iit) pent o or per ons, firms, or corporation has, h.)vc
<br />or will receive direclly i>r indirectiv_ any rcb, tt, 1':c:, gift, cotinmisc;ion or th1rig oi'value on
<br />accouiit of ,,iIch -,,I I e, {Intl
<br />2, C 0111MCtur c ci-1.1I Iu* by sut7mixLnln of this propw ul khat nt ither contracluI, Iiou aEly
<br />of its principals are presently debarred, ,uLgpcn&d, Irrc puled for dc$trrntcrrt. dcckired
<br />incli4)ibIV. OF V01Lifitz11-1ly c.Xcluded from pa rt i ci rat Ion In this Inass wiioil by an .reeleraI
<br />department or agency, and
<br />3_ C'l}I tvaoor ltas not, liar has irly+ assessor to. ri or rlrl a1111i;ite of, Contractor, engaged in
<br />investment activities In Iran_
<br />a. I` or perrtruss uJ tFlls14i1 ical1«n. •`ti:ill" liltnx theclvwr'ptltterlt offraiIrlcl ssrry agency
<br />ire ins;Inlm�_ni{ility If ir;lrl, oi` a ()lhLrwiu. defined It fnd. Code 5-2-Ir's_5-5, as;
<br />amended I roan timl -to-f vn .
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