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Fillable Printable Non-Collusion Affidavit - Florida

Fillable Printable Non-Collusion Affidavit - Florida

Non-Collusion Affidavit - Florida

Non-Collusion Affidavit - Florida

FORM 4 - NON-COLLUSION AFFIDAVIT
STATE OF
COUNTY OF
I state that Iof ,
(Name and Title) (Name of Firm)
amauthorized to make thisaffidavit on behalfofmy firmanditsowner, directors and officers. I am the person
responsible in myfirmfor 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 atindependently 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 beendisclosed to any otherfirmorperson who is a
Provider, potential Provider, Proposal, or potentialProposal, and they will not be disclosed before
Proposal opening.
3. No attempt has been madeorwill be made to induceany firmor persons to refrain fromsubmitting 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 madein good faith and not pursuant to any agreement or discussion with, or
inducement from, any firmor person to submit a complementary or other noncompetitive Response.
5. , its affiliates, subsidiaries, officers, director, and employees
(Name of Firm)
are not currently underinvestigation, byany governmental agency andhave not in the lastthreeyears
been convicted or found liable for any act prohibited byState or Federal law in anyjurisdiction, involving
conspiracy or collusion with respect to Proposal, on any public contract, except as follows:
I state that Iand the named firmunderstand 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 affidavitis, 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
dayof
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
dayof
2014.
NotaryPublic:
MyCommission Expires:
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