NON-COLLUSION AFFIDAVIT - EXHIBIT G.pdf

REQUIRED PROPOSAL SUBMISSION FORM

NON-COLLUSION AFFIDAVIT

PROPOSER PRE-AWARD SELF-CERTIFICATION

This affidavit is to be filled out and executed by the Proposer; if a corporation makes the bid, then by its properly executed agent. The name of the individual swearing to the affidavit should appear on the line marked “Name of Affiant.” The affiant’s capacity, when a partner or officer of a corporation, should be inserted on the line marked “Capacity.” The representative of the Proposer should sign their individual name at the end, not a partnership or corporation name, and swear to this affidavit before a notary public, who must attach their seal.

State of _______________________________________, County of ___________________________________________

I, ____________________________________________________, being first duly sworn, do hereby state that (Name of Affiant)

I am __________________________________ of _________________________________________________________ Capacity) (Name of Firm, Partnership or Corporation) whose business is and who resides at and that ___________________________________________________________________________________________ (Give names of all persons, firms or corporations interested in the bid) is/are the only person(s) with me in the profits of the herein contained Contract; that the Contract is made without any connection or interest in the profits thereof with any persons making any bid or Proposal for said Work; that the said Contract is on my part, in all respects, fair and without collusion or fraud, and also that no members of the Board of Trustees, head of any department or bureau, or employee therein, or any employee of the Authority, is directly or indirectly interested therein.

Signature of Affiant Date

Sworn to before me this _____________ day of __________________________, 20________.

Notary public My commission expires

Seal