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When the prospective Contractor is unable to certify to rnry of the statements heloit,, it shall attach an explanation to this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION <br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY VERIFICATION, NON- <br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE OF UNITED STATES STEEL <br />PRODUCTS OR FOUNDRY PRODUCTS <br />(Must he completed for all quotes and bids. Please type or print) <br />STATE OF Indiana ) <br />)SS.. <br />St. Joseph COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oatlu, affirms under the penalties of perjury <br />that: <br />1. Contractor has not, nor has an), other member, representative, or agent of the firm, company, <br />corporation or partnership represented by hirn, entered into any combination, collusion or agreement with <br />Ony person relative to the price to be bid bi anyone at such letting nor to prevent any person from bidding <br />nor to induce auyoue to refrain from bidding, and that this bid is made %without reverence to any other bid and <br />xyithout any agreement, understanding or combination with any other person in reference to such bidding. <br />Contractor further says that no person or persons, hnns, or corporation has, have or will receive directly or <br />indirectly, any rebate, fee. gift. commission or thing of N alue on account ot'such sale; and <br />2. Contractor certifies by subnussion of this proposal that neither contractor nor any of its principals <br />ore presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded from <br />participation in this transaction by any Federal department or agency; and <br />3, Contractor has not, nor has atuy successor to, nor an affiliate of, Contractor, engaged ill <br />investment activities in Iran. <br />For purposes of this Certification, `'Iran" means the government of Iran and an -, agency <br />or ins ti-tinicntalitr of Iran. or as otherwise defined at Ind. Code -22-I6.�-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 if 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: <br />or <br />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 />fork --live (45) days or more, il'that person will (1) use the credit to provides <br />goods and services itu the energy sector in Iran; and (ii) at the tine the <br />Financial institution extends credit, is a person identified on list published by <br />the Indiana Department of Administration. <br />Version 1€ /17/2017 Contractor's Bid for Public Works - 4 <br />