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K'hen <br />fhFProspecti►Ae Contrartrrr is unable fo rerti to any of the statements below, if shall attack an explanation to <br />this Affidavit. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFIDAVIT, <br />CERTIFICATION REGARDING INVESTMENT WITH IRAN, EMPLOYMENT ELIGIBILITY <br />VERIFICATION, NON-DISCRIMINATION COMMITMENT AND CERTIFICATION OF USE <br />OF UNITED STATES STEEL PRODUCTS OR FOUNDRY PRODUCTS <br />(Must be completed for all quotes and bids. Please type or print) <br />STAB OF -V�a� ? <br />�YA� )SS. - <br />COUNTY <br />) <br />The unde signed Contractor, being duly sworn upon his/her/its, oath, affirms under the penalties of perjury that: <br />I • Contractor has not, nor has any other member, representative, or agent of the firm, <br />company, corporation or partnership represented by him, entered into any combination, collusion <br />or agreement with any person relative to the price to be bid by anyone at such letting nor to prevent <br />any person from bidding nor to induce 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 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; <br />and <br />3. Contractor has not, nor has any successor to, nor an affiliate of, Contractor, engaged in investment <br />activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government of Iran and any agency or <br />instrumentality of Iran, or as otherwise defined at Ind. Code § 5-22-16.5-5, as amended from <br />time -to -time. <br />h. As provided by Ind. Code § 5-22-16.5-8, as amended from time -to -time, a Contractor is <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 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 <br />the energy sector in Iran; 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 />es not Irnowingly employ or contract with an unauthorized alien, nor retain <br />4. CQntctor act with a person that the Contractor subsequently learns is an <br />or 00 Page _ 9 unauthoriz> <br />sty employ Public Works ©note <br />Version 912912029 <br />