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When the prospective Contractor is unable tocertify *, any oythe statements below, ushall attach onexplanation mthis Affidavit.
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, CERTIFICATION REGARDING
<br />INVESTMENT WITH |RAN,EMPLOYMENT ELIGIBILITY VERIFICATION, NDN'03CR|Nl|NATION COMMITMENT
<br />AND CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS
<br />STATE OF
<br />(Must becompleted for all quotes and bids. Please type or print)
<br />)S5:
<br />COUNTY
<br />The undersigned Contractor, being duly sworn upon hb/her/itsoath, affirms under the penalties ufperjury thau
<br />1. Contractor has not nor has any other member, representative, or agent of the firm, company,
<br />corporation or partnership represented by him, entered into any combination, collusion or agreement
<br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person from
<br />bidding no/tu induce anyone to refrain from bidding, and that this bid is made without reference to any
<br />other bid and without any agreement, understanding or combination with any other person in
<br />reference to such bidding. Contractor further says that no person o/persons, firms, or corporation has,
<br />have or will receive directly or indirectly, any rebate, fee, gift, commission orthing ofvalue on account
<br />ofsuch 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 agency; and
<br />1 Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in
<br />investment activities in Iran.
<br />For purposes of this Certification, "Iran" means the government of Iran and any agency or
<br />instrumentality ofIran, or as otherwise defined at Ind. Code g 5-22'16.5.5' as amended
<br />from time -to -time.
<br />b. 4aprovided byInd. Code §5-33,1G.5-8,asamended from bme-to-time,aContractor |s
<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 />ii Contractor, its successor orits affiliate, bafinancial institution that extends twenty
<br />million dollars ($20,000,000) or more in credit to another person for forty-five (45)
<br />days or more, if that person will (i) use the credit to provides goods and services in
<br />the energy sector in Iran; and (ii) at the time the financial institution extends credit,
<br />is a person identified on list published by the Indiana Department of Administration,
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