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fis0l 111..¢,�:E <br />O. ; <br />CITY OF SOUTH BEND, INDIANA 41 ; <br />SELLER'S QUOTE FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND -' <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />QUOTE NAME 125-010 2025 Lamppost Program <br />March 1411, 2025 at 9:00am South Bend Time — submit electronic quotes to <br />FOR QUOTES DUE labreha!2southbendin.gov <br />Date: Firm: C-avvqk Sny*t 1 C bola r- <br />Address: io.i ii>5 — t vv, vw I Carte ► - T2>i vc4 . <br />City/State/Zip: ��acC►�Sj��>� ��� Telephone Number. 2• (off- j"" <br />Agent of Firm (if Applicable): —G1 Y-tC-*yf-1 Com "'u.0 1C. Sa <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF C3t Gy 4L ) <br />) SS: <br />Isvv i n'it-•� � COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of <br />perjury that: <br />I . 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, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. 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 />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged <br />in investment activities in Iran. <br />Version 8 — 02/25/14 <br />