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When the prospective Conti -actor is unable to certify to any of the statements below, it shall aita�h an explanation to this Affidavit,
<br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFI.. AVIT, CERTIFICATION
<br />REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILIT-1 VERIFICATION, NON-
<br />DISCRIMINATION COMMITMENT AND CERTIFICATION OF USOF UNITED STATES
<br />STEEL PRODUCTS OR FOUNDRY PRODUCT i
<br />(Must be completed for all quotes and bids. Please type orlprint)
<br />STATE OF
<br />SS:
<br />COUNTY
<br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the Oenalties of perjury that:
<br />1. Contractor has not, nor has any other member, representative, or gent of the firm, company,
<br />corporation or partnership represented by him, entered into any combing ion, collusion or agreement
<br />with any person relative to the price to be bid by anyone at such letting nor to prevent any person
<br />from bidding nor to induce anyone to refrain from bidding, and that this bid is made without
<br />reference to any other bid and without any agreement, understanding or combination with any other
<br />person in reference to such bidding. Contractor further says that no erson or persons, firms, or
<br />corporation has, have or will receive directly or indirectly, any rebate, f e, gift, commission or thing
<br />of value on account of such 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 />3. Conti -actor has not, nor has any successor to, nor an affiliate of, Con ractor, engaged in investment
<br />activities in Iran.
<br />a. For purposes of this Certification, "Iran" means the governme t of Iran and any agency or
<br />instrumentality of Iran, or as otherwise defined at Ind. Code § -22-,16.5-5, as amended from
<br />time-to-tirne.
<br />b. As provided by Ind. Code § 5-22-16.5-8, as amended from time-t time.. a Contractor is
<br />engaged in investment activities in Iran if either:
<br />i. Contractor, its successor or its affiliate, provides goods oservices of twenty million
<br />dollars ($20,000,000) or more in value in the energy sector of Iran; or
<br />ii. 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 or more, if that person will (i) use the credit to provides goods and services in the
<br />energy sector in Iran; and (ii) at the time the financial institution extends credit, is a
<br />person identified on list. published by the Indiana Department of Administration.
<br />4. Contractor does not knowingly employ or contract with an um
<br />employee or contract with a person that the Contractor subsequently I
<br />6zed alien, nor retain any
<br />s is an unauthorized alien.
<br />Version 4/2/2019 Page - 12 1 Public Works Quote
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