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nro� <br />fir ��`�S�j•!t &it��, <br />y/f <br />Y;4 <br />A;/ <br />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 />trrx <br />BID NAME Janitorial Supplies 2018 <br />FOR BIDS DUE June 12, 2018, 9:30 a.m., local time <br />Bidder <br />Date: 6•-6-2018 (Firm): HP Products Corporation <br />Address: 4220 Saguaro Trail <br />City/State/Zip: Indianapolis, IN 46268 Telephone Number: 800-457-0916 <br />Agent of Bidder (if Applicable): Cy Nahvi, General Manager <br />When the prospective Conty actor is miable to certify to any of the statements below, it shall attach an eaplo7ation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <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 hidiana <br />) SS: Indianapolis <br />Marion COUNTY) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of <br />perjury 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 pet -son from bidding not, to induce anyone to refrain from bidding, <br />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 />Contractor further says that no person or persons, firms, or corporation has, have or will <br />receive directly or indirectly, any rebate, fee, gift, commission or thing of value on account <br />of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any of its <br />principals are presently debarred, suspended, proposed for debarment, declared ineligible, or <br />voluntarily excluded from participation in this transaction by any Federal department or <br />agency; and <br />