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When the prospective Contractor is unable to certify to.any of the statements below, it $hap attach an explanation <br />to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT EdGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL <br />PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all :quotas and bids, Please type or print) <br />STATE OF Indiana�� ) <br />Elkhart } 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, enteredinto any combination, collusion <br />or agreement with any.person relative to the price to be bid by anyone at such letting not to prevent <br />any person from bidding nor to induce anyone to retrain from bidding, and that this bid is made <br />without reference to any other bid and without any agreement, understanding or combination with <br />any other person In reference to such bidding. Contractor:further says that no person or persons; <br />firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, commission <br />or thing of value on account of such sale; and <br />2, Contractor certifies by submission of this proposal that neither contractor nor any of its <br />f principals are presently debarred, suspended; proposed for debarment, declared ineligible, or <br />\. voluntarily excluded. from partiQlpatlon in this transac€ion by any Federal department or agency; <br />and <br />'S. Contractor has not, nor has any successor to, nor are affillate of, Contractor, engaged in <br />Investment activities in Iran. <br />a. For purposes of this Certif!cation,'`Iran' means the government of Iran and .any agency <br />or Instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22A6.5-5, as <br />amended from time -to -time. <br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time-to=time, a Contractor <br />is engaged In Investment activities In Iran it either: <br />I. Contractor, .its successor or its affiliate, provides goods or services of twenty <br />million dollars ($20,000,000) or more In value In the energy sector of Iran; or <br />It. Contractor, its successor or its affiliate, is a financial Institution that extends <br />twenty million dollars ($20,000,000) or more in credit to another person for <br />forty-five (45) days or more, if that person will (1) use the credit to provides <br />goods and services in the energy sector In Iran; and (€1) at the time the <br />financial institution extends credit, is a person Identified on list published by <br />the Indiana Department of Administration. <br />4. Contractor does not knowingly employ or contract with an unauthorized alien,. nor retain <br />any employee or contract with a person that the Contractor subsequently learns is an Unauthorized <br />alien. Contractor agrees that he/she/it shall enroll in and verify the work eligibility status of .all of <br />Contractor's newly hired employees through the E-Verify Program as defined by I.C. 22-5-1.7.3. <br />i <br />Version 1 ti1171201.7 Contractor's Bid forPublic works - 4 <br />117.047-A Vietnam Veteran's Memorial Relocation <br />