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EXHIBIT G <br />NON - DEBARMENT, NON - COLLUSION AND <br />NON- DISCRA41NATION AFFIDAVIT <br />STATE OF INDIANA ) <br />) SS: <br />COUNTY OF ST. JOSEPH ) <br />The undersigned, being duly sworn on oath, hereby certifies, on behalf of <br />( "Tenant'), as follows: <br />1. That the undersigned is duly authorized and is competent to certify to the statements contained <br />herein on behalf of Tenant. <br />2. That neither it nor its principals are presently debarred, suspended, proposed for debarment, <br />declared ineligible, or voluntarily excluded from participation in this transaction by any Federal department <br />or agency. <br />3. That Tenant has not, nor has any other member, representative, or agent of the firm, company, <br />corporation or partnership represented by the firm, entered into any combination, collusion or agreement <br />with any person relative to the price to be offered by any person nor to prevent any person from making an <br />offer nor to induce anyone to refrain from making an offer and that this offer is made without reference to <br />any other offer. <br />4. That Tenant hereby agrees to abide by the following nondiscrimination commitment, which shall <br />be made a part of any contract that Tenant may henceforth enter into with the City of South Bend, Indiana <br />or any of its agencies, boards or commissions: <br />Tenant agrees not to discriminate against any employee or applicant for employment in <br />the performance of this contract with privileges of employment, or any matter directly or <br />indirectly related to employment, because of race, religion, color, sex, handicap, national <br />origin or ancestry. Breach of this provision may be regarded as a material breach of the <br />contract. <br />10 <br />Name: <br />Title: <br />Subscribed and sworn to before me this day of 20 <br />, Notary Public <br />Resident of St. Joseph County, hidiana <br />My commission expires: <br />