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10140"W"'Al <br />110IM1110,11 <br />71,971M.-I Ili 117, Y-"% Rez, 510171,711 1"Vil'A 011: 11l 101 M4411414 4: <br />-MMIRFRITIM, MIMI IIIJIM Za"amriml-1- MIRITUTIL-70 <br />Date: 12/05/2017 Firm: <br />Address: i(oo -C> <br />City/State/Zip: ( (Z­ <br />­1�-�"'�"�4' L9 <br />)H,, Telephone Number: <br />Agent of Firm (if Applicable): <br />When the prospective Contractor is unable to certify to any of the statements below, itshall attach an explanation to thisAffi(lavif. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIF ICATION RE, GARDING INVE STME NT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VEIWICATION, 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 Quotes. Please type or print) <br />STATE OF OWE" <br />) SS: <br />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, 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 Quote by anyone at such <br />letting nor to prevent any person from Quoteding nor to induce anyone to refrain from <br />Quoteding, and that this Quote is made without reference to any other Quote and without <br />any agreement, understanding or combination with any other person in reference to such <br />Quoteding. Contractor further says that no person or persons, firms, or corporation has, <br />have or will receive directly or indirectly, any rebate, fee, gift, commission or thing of <br />value 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 />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />Ver. 5 — 10122112 <br />