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When rh¢ prosp¢criv¢ Cwr[rneror is rmnb!¢ ro cerr� ro nny ofrh¢ sror¢menrs bclnw, !r shn![ ¢r[¢ch nn plan¢rlon ro [his A;�dnvie. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH II2AN, EMPLOYMENT ELIG]BII.ITY VERIFICATION, NON- <br />DISCRIM[NATION COMMITMENT AND CERTIFICATION OF USE OF UNTTED STATES STEEL <br />PRODUCTS OA FOUNDRY PRODUCTS <br />(Must be completed for al3 quotes end bids. Please type or privt) <br />STATE OF Indlatla ) <br />SS: <br />Elkhart COiiNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />chat: <br />1. Covtactor has not, nor has any other m mbar, representative, m agent of the Frm, c mpany <br />corporation or partnership represcnrted by him, entered ivto any combination, collusion or agreement with <br />any person relative to the price to be bid by anyone at such Iening mr to prevent any person from bidding <br />or fo induce anyone to refraiv from bidding and that [his bid is made without reference to any other bid and <br />without any agrecaaent, understandivg or combination with any other person in retemnce to such bidding. <br />Contractor further says that no person or persons, Erns, or corporaton has, have or will receive directly or <br />indirecdy, any rebate, fee, gi$ commission or th:vg of valve on accomrt o£ such sale; and <br />2. Conimetor ecrtifies by submission of this proposal [hat neither coatcactor nor any o£ its principals <br />re presently debarred, suspended, proposed for debarment, declared ineligible, or voluntardy excluded from <br />per6cipetion in this transaction by any Federal department or agency and <br />3. Contractor has not, nor has any successor to, nor an affiliate o£, Contmctor, engaged in <br />investment activities in Iran. <br />a. For purposes o£this Certification, "Iran" means the government of Iran and any agency <br />or instrumentality of Iran, or as otherwise de£med at Ind. Code § 5-22-16.5-5, as <br />amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time-to-timq a Contractor <br />is engaged in investment activities in Iran if either: <br />r. Contractor, its successor or its affiliate, provides goods or services o£twenty <br />million dollars ($20,000,000) or more in value in the energy sector o£Imn; <br />or <br />ii. Contractor, its successor or its affiliate, is a Fnencial institution that extends <br />twenty million dollars ($20,000,000) or more in credit to another person £or <br />forty-five (45) days or more, if that person will (i) use the credit to provides <br />goods and services in the energy sector in Iran; and (ii) at the time the <br />financial institution extends credit, is a person identified on list published by <br />the Indiana Department of Administ[ation. <br />4. ContracNr does not knowingly employ o ontract with a authorized alien, n retain any <br />mPloyee or contract with a Person that the Contracmr subsequently learns s an unauthorized alien. <br />Version O9/29/202t Contractor's Bid for Pnblic Works - 4 <br />