Free Microsoft Word - 47157.DOC - Indiana

NON-COLLUSION STATEMENT
State Form 47157 (R2 / 6-99)

STATE OF: _______________________________ COUNTY OF: _________________________________

SS:

NAME OF COMPANY

STREET, CITY AND ZIP
DEPOSES AND SAYS UPON HIS (OR HER) OATH THAT:

The undersigned, being duly sworn on oath says, that he is the contracting party, or that he is therepresentative, 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. I swear or affirm that the information I have entered on this form is correct. I understand that making a false statement on this form may constitute the crime of perjury.

SIGNATURE

DATE

PRINTED/TYPED NAME