Free 04391.PDF - Indiana

NON-COLLUSION AFFIDAVIT
State Form 4391 (R4 / 1-00)

STATE OF: ________________________________________________ COUNTY OF _______________________________________________

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SS:

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.

Signature

Printed name

Title

Company

Before me, a Notary Public in and for said County and State personally appeared, ______________________________________________ , who acknowledged the truth of the statements in the foregoing affidavit on this _______________________ day of ______________________, 20 ___ .

Signature of Notary Public

County of residence

Commission expiration date

Printed or typed name of Notary Public