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CITY OF SOUTH BEND, INDIANA <br />SELLER'S BID FOR SALE OR LEASE O'F MATERIALS <br />BID NAME Water Treatment Chemicals 2020-20,24 -re <br />FOR BIDS DUE ril 14,202Q9.,30 AM, Local ren _It -- <br />3/31/2020, Bidder fate: Inc. <br />Date: (Firm): <br />Address: P01 Box 600 <br />City/State/Zip: San Felipe, Tx 77473 Telephone Number: . 9 - 79: ) 885.0005------- <br />Agent of Bidder (if Applicable): Sarah DUffy, Bid Sec. <br />When the prospective Cont)-actor is unable to certify"d <br />to atq, of the statensents helow, it shall attach an explanation to this �,Jfjtavit. <br />WMAMS 01 <br />Mail) I" <br />PRODucrs <br />(IMust be completed for call quotes and, bids. Please type or print) <br />STATE al. TEXAS <br />) SS: <br />AUSTlN COUNTY <br />The undersigned Contractor, being duly sworn upon histher/its oath, affirms Linder the penalties of perjury <br />that: <br />1. Contractor has not, nor has any other member, representative, or agent of the Finn, <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 person front bidding nor to induce anyone to refrain from <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding or combination with any other person in reference to such <br />bidding. Contractor further says that no person or persons, firms, or corporation has, have <br />or will receive directly or indirectly, any rebatc, fee, gift, commission or thing of value on <br />account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor tiny <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded fironi participation in this transaction by ally Federal <br />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. For purposes of tltis Certi f ical ion,"Iran" means the government of Iran and any agency <br />or instrumentality of Iran, or as othenvise defined at Ind. Code § 5-22-16.5-5, as <br />amended from time-to-tirne. <br />