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BID NAME <br />FOR BIDS DUE <br />Address: <br />CITY OF SOUTHBEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />Spec S — One (1) or More 2018 or Newer Emergency Medical Vehicle <br />Aunust 28, 2018 at 9!:30 a.m. <br />Bidder <br />(Firm): <br />19 <br />City/State/Zip: )VkM�� Lit -�t3�rejephone �Number: (0,1,q 3 1,5- - .7 <br />Agent of Bidder (if Applicabie): <br />When lite prospective Contractor is unable to certify to any of the statentents belmv, it shall attach an explanation to this Affulavit. <br />CONTRACTOR'S NON -COLLUSION AND NON, -DEBARMENT AFFIDAVIT, <br />CERTIFICATION RE' GARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />1=111-191LOMI <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF �� did A.�,A <br />) SS: <br />1110ri'vW 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 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 />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in <br />investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and any <br />agency or instrumentality of Iran, or as otherwise defined at Ind, Code § 5-22-16.5-5, <br />as amended fi-om time -to -time, <br />W <br />