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Form No.96(Revised 2000) .,
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BID OF
NoSi .4 —,eie41 c/.9-171-
(Contractor)
avic76
(Address)
(7,4, e/ �.✓ �� 33
FOR
PUBLIC WORKS PROJECTS
OF
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filed
,-
Action taken _
D.
NON - COLLUSION AFFIDAVIT
The undersigned bidder or agent, being duly sworn on oath, says that he has not, nor has any other member,
representative, or agent of the firm, company, corporation or partnership represented by him, entered into any
combination, collusion or agreement with any person relative to the price to be bid by anyone at such letting nor
to prevent any person from bidding nor to induce anyone to refrain from bidding, and that this bid is made without
reference to any other bid and without any agreement, understanding or combination with any other person in
reference to such bidding.
He further says that no person or persons, firms, or corporation has, have or will receive directly or indirectly,
any rebate, fee, gift, commission or thing of value on account of such sale.
OATH AND AFFIRMATION
I affirm under the penalties of perjury that the foregoing facts and information are true and correct to the best
of my knowledge and belief. 2 �,
Dated at J / this r��-� day of c;2 0-0 8
/✓ox
ame of 0 ation
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By / /l!_>��
7 c- , 4,y46
(Title of Person Signing)
ACKNOWLEDGEMENT
STATE OF )
) SS;
COUNTY OF /4,---/-.)
2/- r lip J fei, e.kiS being duly sworn, deposes and says that he is
/ A AJA LX-i of the above -N 161A■-e(t. ciw SA(4. and that the
itle) (Name of Organization)
statements contained in the foregoing bid, certification and affidavit are true and correct.
�'"
Subscribed and sworn to before me this 3 j da y of 06--�v bez_ ,
ry Public
My Comission Expires: fil A 71, Zo(/
Count y of Residence: �1-4
Prescribed by State board of Accounts Boyce Forms•Systems.Muncie,IN 1240 Form No.96(Revised 2000)
CONTRACTORS BID FOR PUBLIC WORKS
PART I
(To be completed for all bids)
(Please type or print)
Date:
1. Governmental Unit (Owner): �l%�y �� ��,2i•��s"� r �r✓.
2. County: /7/9-,x; /t.>
3. Bidder (Firm): NO it � �_k:e /
Address:
City/State: (/9'
//�1./)'> / ` v. 0 23
4. Telephone Number: 312/ 76-2 z- )
5. Agent of Bidder (if applicable): ✓% ,r�le
Pursuant to notices given, the undersigned offers to furnish labor and/or material necessary to complete the
public works project of �e,� ✓s'f [ rd;�� �� /! J�/it), is ,/
(Governmental Unit) in accordance with plans and specifications prepared by
S!�lf -- /o olio l," fiu/ and dated for the sum of
't 90 ' M I 2 a a`? jr.e ti psi-.31 )c09$ e 9 9 %cy✓c /
The undersigned further agrees to furnish a bond or certified check with this bid for an amount specified in the
notice of the letting. If alternative bids apply, the undersigned submits a proposal for each in accordance with the
notice. Any addendums attached will be specifically referenced at the applicable page.
If additional units of material included in the contract are needed, the cost of units must be the same as that
shown in the original contract if accepted by the Governmental Unit. If the bid is to be awarded on a unit basis,
the itemization of the units shall be shown on a separate attachment.
The Contractor and his subcontractors, if any, shall not discriminate against or intimidate any employee, or
applicant for employment, to be employed in the performance of this contract, with respect to any matter directly
or indirectly related to employment because of race, religion, color, sex, national origin or ancestry. Breach of this
covenant may be regarded as a material breach of the contract.
CERTIFICATION OF USE OF UNITED STATES STEEL PRODUCTS
(If applicable)
I, the undersigned bidder or agent as a contractor on a public works project, understand my statutory obligation
to use steel products made in the United States. I.C. 5-16-8-2. I hereby certify that I and all subcontractors employed
by me for this project will use U.S. steel products on this project if awarded. I understand that violations hereunder
may result in forfeiture of contractual payments.