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t <br />CITY OF SOUTH BEND, INDIANA WACK <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />AND NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT AND I S 1 65 , <br />NON.-D.11SCRIMINATION COMMITMENT FOR SELLERS <br />Spec G — One (1) or More 2020 or Newer 27 Cubic Yard Single Arm Side Loading Refuse <br />BID kJAIfE Truck <br />Bidder <br />Date, r. <br />(Firm): <br />Address: <br />City/State/Zip'. ------- <br />Agent of Bidder (if AppHcabi)T.__± <br />1- <br />When the prospective Contractor is unable to certift to any of `tire statements below, it shall attach an explanation to this Affidavit. <br />CONTRACTOR'S NON-COLLUSIONAND NON-DEBARMENTAFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT <br />ELIGIBILITY VERIFICATION, NON-DISCRIMINATION COMMITMENT AND <br />CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS OR FOUNDRY <br />PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STATE OF _J <br />SS: <br />L-os h 4—e—COIJNTY <br />'rhe undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties of per' Jury <br />that: <br />1. Contractor has not, nor has any other rnernber, representative, or agent of the firm, <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 frorn 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, firm. s, or corporation has, have <br />or will receive directly or indirectly, any rebate, fee, gift, commission or thing of value <br />on account of such sale; and <br />2. Contractor certifies by submission of this proposal that neither contractor nor any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded from participation, in this transaction by any Feder -al <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 />W <br />