Fillable Printable Non-Collusion Affidavit - Florida

Non-Collusion Affidavit - Florida

FORM 4 - NON-COLLUSION AFFIDAVIT

STATE OF

COUNTY OF

I state that I of ,

(Name and Title) (Name of Firm)

am authorized to make this affidavit on behalf of my firm and its owner, directors and officers. I am the person

responsible in my firm for the price(s) and amount(s) of this Response, and the preparation of the Response. I

state that:

1. The price(s) and amount(s) of this Response have been arrived at independently and without consultation,

communication or agreement with any other Provider, potential provider, Proposal, or potential Proposal.

2. Neither the price(s) nor the amount(s) of this Response, and neither the approximate price(s) nor

approximate amount(s) of this Response, have been disclosed to any other firm or person who is a

Provider, potential Provider, Proposal, or potential Proposal, and they will not be disclosed before

Proposal opening.

3. No attempt has been made or will be made to induce any firm or persons to refrain from submitting a

Response for this contract, or to submit a price(s) higher that the prices in this Response, or to submit any

intentionally high or noncompetitive price(s) or other form of complementary Response.

4. The Response of my firm is made in good faith and not pursuant to any agreement or discussion with, or

inducement from, any firm or person to submit a complementary or other noncompetitive Response.

5. , its affiliates, subsidiaries, officers, director, and employees

(Name of Firm)

are not currently under investigation, by any governmental agency and have not in the last three years

been convicted or found liable for any act prohibited by State or Federal law in any jurisdiction, involving

conspiracy or collusion with respect to Proposal, on any public contract, except as follows:

I state that I and the named firm understand and acknowledge that the above representations are material and

important, and will be relied on by the State of Florida for which this Response is submitted. I understand and my

firm understands that any misstatement in this affidavit is, and shall be treated as, fraudulent concealment from

the State of Florida of the true facts relating to the submission of responses for this contract.

Dated this

day of

2014.

Name of Organization:

Signed by:

Print Name

being duly sworn deposes and says that the information herein is true and sufficiently complete so as not to be misleading.

Subscribed and sworn before me this

day of

2014.

Notary Public:

My Commission Expires: