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<br />When tine prospective Contractor is unable to certify to arty Of the slatenjenty below, it shall attach an exP111nation to thi A, Jitialit,
<br />CONTRACTOR'S NON -COLLUSION AND NON -DE 13ARAlENT AFFIDAVIT,
<br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY
<br />VERIFICATION, NON-DISCRIMINATFON COMMITMENT AND CERTIFICATION OF USE
<br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />(Must be completed for all quotes and bids. Please type or print)
<br />STATE OF
<br />SS:
<br />14A-y- COUNTY
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of perjury that:
<br />1'.. Contractor has not, nor has any other member, representative, or agent of the firm,
<br />company, corporation or partnership represented by hirn, entered into any combination, collusion
<br />or agreement with any Person relative to the price to be bid by anyone: at such letting nor to
<br />prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid
<br />is made without reference to any other bid and without any agreement, understanding or
<br />combination with any other person in reference to such bidding. Contractor further says that no
<br />person or persons, firms, or corporation. has, have or will receive directly o indirectly, y
<br />rebate, fee, gift, c I r c an
<br />commission or thing of value on account of such sale; and
<br />2. Contractor certifies by submission of this proposal that neither contractor or y of it
<br />principals are presently debarred, Ile I n an s
<br />suspended, proposed for debarment, declared ineligible, or
<br />voluntarily excluded from participation in this transaction by any Federal department or agency;
<br />and
<br />3. Contractor has, not, nor has any successor to, nor an affiliate Of, Contractor, engaged in
<br />investment activities in It -an,
<br />a. For Purposes of this Certification, "Iran" means the government of Iran and any agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from
<br />time -to -tinge.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as aniended from tune -to -tinge, a Contractor is
<br />engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods or services of twenty million
<br />dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />ji- Contractor, its successor or its affiliate, is a financial institution that extends twenty
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />days of more, if that person will W use the credit to provides goods and services in
<br />Non-Coillision Non-DebalineW Affidavit Non Iran Farm
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