Form 47157 - Non-Collusion Statement - Indiana printable pdf download

Form 47157 - Non-Collusion Statement - Indiana

NON-COLLUSION STATEMENT

State Form 47157 (R2 / 6-99)

: _______________________________

STATE OF



_________________________________

SS:

COUNTY OF:

NAME OF COMPANY

STREET, CITY AND ZIP

DEPOSES AND SAYS UPON HIS (OR HER) OATH THAT:

The undersigned, being duly sworn on oath says, that he is the contracting party, or that he is

therepresentative, agent, member, or officer of the contracting party, that he has not, nor has any other

member, employee, representative, agent or officer of the firm, company, corporation or partnership

represented by him, directly or indirectly, entered into or offered to enter into any combination, collusion

or agreement to receive or pay, and that he has not received or paid, any sum of money or other

consideration for the execution of the annexed contract other than that which appears upon the face of

the contract.

I swear or affirm that the information I have entered on this form is correct. I understand that making a

false statement on this form may constitute the crime of perjury.

SIGNATURE

DATE

PRINTED/TYPED NAME

Form 47157 - Non-Collusion Statement - Indiana