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_ Iiri t'er <br />CITY OF SOUTH BEND INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />SPEC E — ONE (1) OR MORE 2021 OR NEWER TRACK DRIVEN TROMM�6`.4 S ' <br />BID NAME SCREEN _ slis <br />FOR BIDS DUE September 28, 2021; 5:00 a.m. p <br />Bidder <br />Date: 4f�ZJZ61l (Firm): of ung EQ.41_L-DWt-ett,'�' <br />Address: _ _ _2�2-A' t�c•F'ocy+nc�snct? t U <br />City/State/Zip: CdL*ANlNs {_r(320 Telephone Number: <br />Agent of Bidder (if Applicable): --- —_- -- -- <br />When the prospective Contractor is unable to certify to any of the statements below, it sha11 attach an explanation to this <br />Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITII IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR <br />FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF ©V%�i_o ) <br />) SS: <br />tr,"LcGvx COUNTY ) <br />The undersigned Contractor, being duly swom upon his/her/its oath, affirms under thepenalties ofperjury <br />that: <br />1. Contractor has not, nor has any other member, representative, or agent of the firm, <br />company, corporation or partnership represented by him, entered into any combination, <br />collusion or agreement with any person relative to the price to be bid by anyone at such <br />letting nor to prevent any person from bidding nor to induce anyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebate, fec, gift, commission or thing of value on <br />account of such sale; and <br />Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation in this transaction by any Federal <br />department or agency; and <br />