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lYhen theprospective Contractor is unable to certify to any of the statentents below, 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 be completed for all quotes and bids. Please type or print)
<br />STATE OF Indiana
<br />St. Joseph 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 niember, representative, or agent of the firm, company,
<br />corporation or partnership represented by hirn, entered into any combination, collusion or, agreement Mill
<br />any person relative to the price to be bid by anyone at such letting not' to prevent any person front bidding
<br />nor to induce anyone to refrain &orn bidding, and that this bid is made without reference to any other bid and
<br />without any agreement, 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 receive directly or
<br />indirectly, any rebate, fee, gift, commission or thing Of value on account of such sale; and
<br />Z Contractor certifies by submission ofthis, proposal that neither contractor nor any of its principals
<br />are presently debarred, suspended, I)roposed fordebarnient,declared ineligible, orvoluntarily excluded fiorn
<br />participation in this transaction by any I"ederall department or agency; and
<br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investment activities in Iran.
<br />a. Forpurposes of this Certification, "Iran" itimins the government of Iran and any agency
<br />Or instrurnentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as
<br />amended ftoili thine -to -tithe,
<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 />Contractor, its successor, or its affiliate, provides goods or services of twenty
<br />Milh011 dollars ($20,000,000) or more iii value in the energy sector of fran,
<br />or
<br />ii, Contractor, its successor or its affiliate, is a financial institution that extends
<br />twenty million dollars ($20,000,000) or nlol°e in credit to another person for
<br />forty-five (45) days or more, if that Pei -soil Will (i) use the credit to provides
<br />goods and services ill tile ellergy sector in Iran; and (ii) at tile time the
<br />financial institution extends credit, is a person identified on list published by
<br />tile Itidiana Department of Administration.
<br />Version 4/2/2019 Contractor's Bid for Public Works - 4
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