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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON DEBARMENT AFFIDAVIT AND <br />NON-DISCRIMINATION COMMITMENT FOR SELLERS <br />Spec AG -- Two (2) More or Less 2018 or Newer'/Z Ton Crew Cab Four Wheel Drive Pickup <br />BID NAME Trucks <br />FOR BIDS DUE December 12, 2017 at 9:30 a.m. <br />5 Bidder <br />Date: / � (Firm): ii-- M o-Ln t�I �(1,-7k1Cheyr0W,_TnL <br />�7 <br />Address: Z105 /U, ! j?r �i ree �UiC 53 <br />CitylStatelZip: �1 rV1 osJ k'(� �Tf�l jp�(ojTelephone Number: { 5��) 936 Z I !S <br />Agent of Bidder (if Applicable): <br />When the prospective Contractor is unable to certify to any of the statements below, it shall attach an explanation to this Af -davit. <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 _F-WIAON } <br />) SS: <br />"Ak& ALLY COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury <br />that: <br />1. Contractor has not, not 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 <br />on 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 />M <br />