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NON-COLLUSIVE/ANTI-KICKBACK AFFIDAVIT <br />STATE OF MISSOURI) <br />) SS <br />COUNTY OF ______________) <br />__________________________, being first duly sworn, deposes and says: <br />That (s)he is ____________________ of __________________________ <br />(“Proponent”), the party making the foregoing proposal or bid, that Proponent will comply with <br />and adhere to the provisions of the Copeland Anti-Kickback Act (18 USC 874) as Supplemented <br />in Department of Labor regulations (29 CFR, Part 3), that such proposal or bid is genuine and <br />not collusive or sham; that Proponent has not colluded, conspired, connived or agreed, directly or <br />indirectly, with any other bidder or person, to put in a sham bid or to refrain from bidding, and <br />has not in any manner, directly or indirectly, sought by agreement, collusion, communication, <br />conference, or otherwise, with any person, to fix the bid price of Proponent or of any other <br />bidder, or to fix any overhead, profit or cost element of said bid price, or of that of any other <br />bidder, or to secure any advantage against any person interested in the proposed contract; and <br />that all statements in said proposal of bid are true and that the prices quoted in the attached bid <br />are fair and proper and not tainted by any collusion, conspiracy and connivance and place <br />responsibility on, in addition to the Proponent, its agents, representatives, owners, employees, or <br />parties of interest. <br />PROPONENT: _________________ <br />______________________________ <br />By: __________________________ <br />Title: _________________________ <br />Subscribed and sworn to before me this _______ day of ____________________, 2015. <br />My commission expires:______________________________ <br />Notary Public <br />17 <br /> <br />