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When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to <br />this Affidavit. <br />CONTRACTOR'S NON-COLLUSION AND NON-DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY <br />VERIFICATION, 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 Indiana ) <br />) SS: <br />St. Joseph C OUNTY ) <br />The unders ig ned C ontractor, bein g duly sworn upon hi s/her/its oath , affirm s und e r the penaltie s of perjury th at: <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, 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 thi s bid is made <br />without reference to an y 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 />firm s, or corporation has , have or will receive directly or indirectly , any rebate , fee , gift , <br />commi ss ion or thing of value on account of such sale; and <br />2 . 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 an y Federal department or agenc y; <br />and <br />3. Contractor has not, nor has any s uccessor to , nor an affiliate of, Contractor, en g aged in inve stment <br />activitie s in Iran . <br />a. For purposes of this Certification, "Iran " means the government of Iran and any agency or <br />instrumentality oflran, or as otherwise defined at Ind . Code § 5-22-16 .5-5 , as amended from <br />time-to-tim e. <br />b. As provided by Ind. Code § 5-22-16 .5-8 , as amended from time-to-time, a Contractor is <br />engag ed in investment activities in Iran if either: <br />i. Contractor, its successor or its affiliate , provides goods or services of twenty mill ion <br />dollars ($20 ,000 ,000) or more in value in the energy sector oflran; or <br />ii . 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 (4 5) <br />days or more , if that person will (i) use the credit to provides goods and services in <br />the energy sector in Iran ; and (ii) at the time the financial institution extends credi t, is <br />a person identified on list published by th e Indiana Department of Administration . <br />4. Contractor does not knowingly employ or contract with an unauthorized alien, nor re tain <br />any employee or contract with a person that the Contractor subsequently learns is an unauthori zed <br />Version 1/3/2025 Page -16 Public Works Quote