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RFP: #2302 <br />�'11�89F <br />Purchasing Department <br />Prescribed by the State Board of Accounts Form No. 95 (Rev. 1987) <br />BID, OFFER OR PROPOSAL FOR SALE OR LEASE OF MATERIALS <br />(Defined at I.C. 36-1-2-9.5) PLEASE TYPE OR PRINT GG <br />DATEJZ`O `1-7 <br />1) Governmental Unit: "_S) <br />I W &)j <br />2) County: <br />3) Bidder (Firm): ova B�cd <br />Address: <br />City/State: <br />4) Telephone: <br />5) Agent or Bidder (If Applicable):Le <br />Pursuant to notices given, the undersigned offers bid(s) to pmam , hMa(Governmental Unit) in <br />accordance with the following attachment(s) which specify the class, em number or description; quantity, unit, unit price and <br />total amount. The contract will be awarded by classes or items in accordance with specifications. Any changes or alterations in <br />the items specified will render such bid void as to that class or item, Bidder promises that he has not offered nor received a lesser <br />price than the price stated in his bid for the materials included in said bid. Bidder further agrees that he will not withdraw his bid <br />froze the office in which it is filed. A certified check or bond shall be filed with each bid if required, and liability for breach shall <br />be enforceable upon the contract, the bond, the certified check or both t c e may be, <br />�ORAGENTSI NA URE O; I <br />BID OFFER or PROPOSAL <br />Attach separate sheet listing each item bid based on specifications published by the governing body. Following is an example of <br />the bid format: <br />Class or Item <br />Quantity <br />Unit <br />Description <br />Unit Price <br />Amount <br />p� Q /-� <br />NON -COLLUSION AFFIDAVIT <br />STATE of INDIANA } <br />ss: <br />COUNTY ) <br />The undersigned bidder or agent, being duly sworn on oath, states that he has not (nor has any other member, representative or <br />agent of the firm, company, corporation or partnership represented by him) entered into any combination, collusion or agreement <br />with any person relative to the price to be bid by anyone at such bidding; nor to prevent any person from bidding; nor to induce <br />anyone to refrain from bidding; and that this bid is made without reference to any other bid and without any agreement, <br />understanding, or combination with any other person in reference to such bidding. <br />He further states that no person or persons, firm or corporation has or will receive either directly or indirectly, any rebate, fee, <br />gift,.ga� Sign X tlU'ng.of_yall-e on account of such sale. <br />LaryP bFRISK Lq�� ApYe FbYJ <br />Notary Public - Seai <br />State of Indiana BI (FIRM) f <br />Porter County _— <br />Nly Commission Expires Jul 31, 2022 <br />Signature of Bidder or Agent <br />Subscribed and sworn to before me on this day of / 1�!fP. ax.i_ , 2p%�, <br />f <br />My Commission Expires: %-' , % �- F-�,,4c-- <br />County of Residence: <br />Notary Public - Signature <br />t°-n� <br />ACCEPTANCE Notary Public - Printed Name <br />