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CITY OF SOUTH BEND, INDIANA
<br />SELLER'S BIID FOR SALE OR LEASE OF MATERIALS
<br />BID NAME SPOC S—O'. (1 or M.,. 2018 �), Newer Eimerg—cy Meth —I Vehicle
<br />FOR BIDS DUE 28.2018 9:30 .—
<br />Bidder
<br />Date: t4,�,e 46W exerce"q
<br />Address: tA O_L�aortl kaa-a
<br />City/State/Zip: GftwLL,4,, ak4)j)6,j Telephone Number: (6/7) W (e - g AT,9
<br />Agent of Bidder (if Applicable): A_
<br />Wile" thoprospectjve Coorractor is tionwo to certify to ayattht.tts b.lcw, rtshaff.tth ., expl-1.0— tcthiAftid. vit.
<br />CONTRACTOR'SNON-COLLUSlON AND NOWDEBARMENTAFFI DAVIT,
<br />CER-11FICATION REGARDING INVESTIVIENTWITH IRAN, EMPLOYMENT
<br />ELIGI(ILITYVERIFICATION, NON-DISCRIMI NATION 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 XMJ.0,4
<br />) SS:
<br />COUNTY
<br />The undersigned Contractor, being duty sworn upon his/her/its oath, affirms under the penalties of perjury
<br />that.,
<br />1, 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 person relative to the price to be bid by anyone at such
<br />letting nor to prevent any person from 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. Conti -actor further says that no person or persons, firms, 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 />1 Conti -actor 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 fi-om participation in this transaction by any Federal
<br />department or agency; and
<br />3, Contractor has not, nor has any successor to, nor an affiliate of, Conti -actor, engaged in
<br />investment activities in Iran.
<br />a. For purposes of this Certification, "Iran" means the government of Iran and any
<br />agency or instrumentality of Iran, or as otherwise defined at Ind, Code § 5-22-16.5-5,
<br />as amended from time -to -time.
<br />PA
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