Form 96 - Contractors Bid For Public Work - Indiana Page 5

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SECTION IV CONTRACTOR'S 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 include 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.
SECTION V OATH AND AFFIRMATION
I HEREBY AFFIRM UNDER THE PENALTIES FOR PERJURY THAT THE FACTS AND INFORMATION
CONTAINED IN THE FOREGOING BID FOR PUBLIC WORKS ARE TRUE AND CORRECT.
Dated at ____________________ this ______________ day of __________________, _______
__________________________________________________________
(Name of Organization)
By________________________________________________________
__________________________________________________________
(Title of Person Signing)
ACKNOWLEDGEMENT
STATE OF ______________________)
) ss
COUNTY OF_____________________)
Before me, a Notary Public, personally appeared the above-named _________________________________ and
swore that the statements contained in the foregoing document are true and correct.
Subscribed and sworn to before me this ____________ day of ___________________, ________.
____________________________________________
Notary Public
My Commission Expires:_____________________
County of Residence:________________________

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