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GTY OF SOUTH BEND. IN DIANA <br />_ �� <br />T� <br />SELLER'S BID FOR SALE OR LEASE OF MATERIALS <br />_ <br />BID NAME <br />Wat¢r Treatman[ Chemicals Wastewat¢r 2026-2029 <br />< <br />'� >i�; <br />FOR BIDB DUE <br />April 26, 2026; 9:00 AM, Local Tlma <br />--� <br />..� <br />Date: <br />4/2'I/26 Bidder pol d ne Inc. <br />(Firm): Y Y <br />address; <br />1 Chemical Plant Road <br />City/State/Zip; <br />Riceboro, GA 3'1323 Telephone Number: ( 800)848-7659 Opt. <br />2 <br />Agent of Bidder (if Applicable); <br />Whcn rhepsnspccriv¢ Contacror is unub[c ro cc>rijy ro any Jnc� smrca.curs bNow, )r shin[ amoch an ear /mnarion ro this AJjSdovir. <br />CONTRACTOR'S NON -COLLUSION AND NON -DEBARMENT AFFH)AViT, <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 GEORGIA ) <br />LIBERTY ) S5; <br />COUNTY ) <br />The undersigned Contractor, being duly sworn upon his/her/its oath, affirms under the penalties o£perjury <br />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, <br />collusion or agreement with any parson relative to the price to be bid by anyone at such <br />letting nor to prevent any person from bidding nor to induce aayon¢ to refrain Rom <br />bidding, and that this bid is made without reference to any other bid and without any <br />agreement, understanding oz 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 rebate, fee, giR, 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 any <br />of its principals are presently debarred, suspended, proposed for debarment, declared <br />ineligible, or voluntarily excluded Rom participation in this transaction by any Federal <br />department or agency; and <br />3. Contractor has not, nor has any successor tq nor as affiliate of, Coatractoq engaged in <br />investment activities in Iran. <br />a. For purposes of this Certification, "Iran" means the government o£Iren and any agency <br />or instrumentality of Iran, or as otherwise defined at Ind. Codc § 5-22-16.5-5, as <br />amended from time -to -time. <br />