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When the prospective Contractor is unable fo certify to art}• of the statenrents behl"'. Itshall atfrrch an er-plrrnntrr,n to tills oo1 ffrrluvit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBRATY <br />VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE <br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS <br />(Mint be completed for all quotes and bids. Please type or print) <br />STATE OF.:5_O�_1d"I <br />SS: <br />COUNTY } <br />The undersigned Contractor, being d Ll I y sworn ti Pan h i siberli Its oath, affirms UInd er the penalties of perjury that: <br />1. contractor has not, nor has any other member, representative, or agent of the finri, <br />company, corporation or partnership represented bv him. entered into any combination, collusion <br />or agreement with any person relative to the price to be bid by anyone at such letting Warta prevent <br />any person from bidding nor to induee anyone to refrain from bidding... and that this bid is made <br />without reference to any other bid and without any agreement, understanding or combination with <br />any other person in reference to such bidding., Contractor further says that no person or persons, <br />firms, or corporation has, have or will receive directly or indirectly, any rebate, fee, gift, <br />commission or thing of vaiue 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; <br />and <br />contractor has not, nor has any sticcessar to, nor an affiliate of, Contractor., engaged in investment <br />activities in Iran. <br />a. For purposes of this certification, ''Iran" means the govemment of Iran and any agency or <br />Instrumentality of [ran, or as otherwise defined at Ind. Code § 5-12-16.5-5. as amended from <br />time -to -time. <br />b. As provided by Ind, Cody y� 5-111111111111-16.5-8, as amended from time -to -time, a Contractor is <br />engaged in �nvestment 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 or its affiliate, is a financ'l'al 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 bran; and (ii) at the time the financial institution extends credit, is <br />a person identified on list published by the Indiana Department of Administration. <br />4. Contractor does not knowingly employ or contract with an unauthorised align, nor retain <br />any employee or contract with a person that the Contractor subsequently learns is an unauthorized <br />Version 2/14/2020 Page - 12 Public Works Quote <br />I <br />