|
When the prospective Contractor is anable to certify to any of the statements below, it shall attach an explanation to
<br />pais Affldavit.
<br />CONTRA.CTOR�S '-NO.N-C' LLUSION ANIS NON -DEBARMENT AFFIDAVIT,
<br />CERTIFICATION REGARDING INVESTMENT WIT14 IRAN, EMPLOYMENT ELIGIBILITY
<br />VERIFICATION, NON-DiS'CR114�NATIONT COAL NUT14 ENT AND CERTIFICATION OF USE
<br />OF UNITED STAVES STEEL PRODUC Y S OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. please type or print)
<br />STATE OF
<br />Syph COUNTY
<br />The undersigned Contractor, 'neing l! �_'y swDrn up or his/!wilts oath, affirms under the penalties of perjury that:
<br />1. Contractor has nor i,as any other member, representative, or agent of the firm,
<br />company, corporation _r-ersnip representee: ,y him, entered into any combination, collusion
<br />or agreement w 'J,- =•n :, : the p- v cid by anyone at such letting nor to prevent
<br />any person from mid, LG_- :-:. zduczt anyot e �o refrain from bidding, and that this bid is made
<br />without reference to an-, :,trier o, . and without any agreement, understanding or combination with
<br />any other person in re `. ':o such bidding. Contractor further says that no person or persons,
<br />firms, or corporation :~:: r .1: _ receive directly or indirectly, any rebate, fee, gift,
<br />commission or thing - of sucl; sale: and
<br />2. Contractor c _.i:=-nission of this rmoosal that neither contractor nor any of its
<br />principals are iproposed for debarment, declared ineligible, or
<br />voluntarily excludce =-::: _ _>. :_ =-ansaction by any Federal department or agency;
<br />and
<br />3- Contractor has o _ - o- has any su,:c3ssor to, nor an affiliate, of, Contractor, engaged in investment
<br />activities in Iran.
<br />a. For purposes of ::pis Ce-titication. "era.,:" reans the government of Iran and any agency or
<br />instrumentality o -gran, or as otiier«ise defined at Ind. Code § 5-22-16.5-5, as amended from
<br />l7. AS i6rC Vii �: ..._.. -_ _ 22 }.=�-�, as �inel-ided front tint -to -time, a Contractor is
<br />engages '-= _..iran if either:
<br />-ts aftil_are, provides goods or services of twenty million
<br />_JG j a r_�ore in value in the energy sector of Iran; or
<br />.,sir, cr i Ls aLl l atc, is a financial institution that extends twenty
<br />c, _ }20'006'000) or more in credit to another person for forty-five (45)
<br />..: .:7e file crtidit to provides goods and services in
<br />s�the time t e ttnancial institution extends credit, is
<br />t li d 'y tl c Indiana Department of Administration.
<br />4. Contractor c'ocs °_c.. co-aamc-1 -�v',th an unauthorized alien, nor retain
<br />_3a '_- _ - ire Coin': -_actor subsequently learns is an unauthorized
<br />any employee or co
<br />Version 2/94/2020 =age - 9 Public Works Quote
<br />
|