Form 47157 - Non-Collusion Statement
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1NON-COLLUSION STATEMENT
State Form 47157(R / 11-97)
STATE OF:
}
SS:
COUNTY OF:
PRINTED NAME
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 the representative, 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.
SIGNED
DATE
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