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<br />ire contractor is rnurhlr toperrdf1' to an of the claft'nrcnt.+ helon', i1 shQl1 attach an explurrurlon to thil 4 ffd,n,i4
<br />tr4TRACTOWS NON -COLLUSION AND NON -DEBARMENT AFFIDAN'IT
<br />c,%TION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY
<br />TION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE
<br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF��� )
<br />SS:
<br />rD COUNTY )
<br />The undersigned Contractor, being duly sworn upon hislher/its oath, affirms under the penalties of perjury that:
<br />1. Contractor has not, nor has any other member, representative, or agent of the fifrrt,
<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.
<br />Contractor certifies by submission of this proposal that neither contractor nor any of its
<br />principals are presently debarred, suspended, proposed for debarment, 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 in investment
<br />activities in Iran.
<br />For purposes of this Certification, '•Iran" means the government of Iran and any agency or
<br />instrumentality of Lan, 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 -time, 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 ($20,000,00o) or more in value in the energy sector of [ran; or
<br />IL 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 6) use the credit to provides goods and services in
<br />the energy sector in Iran; and 6i) at the time the financial institution extends credit, is
<br />a person identified on list published by the Indiana Department of Administration.
<br />4. Contractor does not knowing y
<br />1 employ or contract with an unauthorized alien, nor retain
<br />any employee or contract with a
<br />Version 2r1a12t]20 person that the Contractor subsequently learns is an unauthorized
<br />Page - 3 Public Works Quote
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