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6.D. - Page 108 of 170
<br />Request for Qualifications:
<br />General Park Building Construction, Retrofit, Maintenance, and/or Repairs
<br />FORM G
<br />NON -COLLUSION AFFIDAVIT TO ACCOMPANY RESPONSES
<br />I/We, dJPRLIr s E, 1<Au1=M#d
<br />being first duly sworn, deposes and states: That the undersigned
<br />ORCs»iiv
<br />(Insert "Sole Owner", "General Partner", "President", "Secretary", or other proper title)
<br />is of THE PUBLIC A 66TA OOM dOMP41 i
<br />(Name of firm / business entity)
<br />Who submits herewith to City of Los Angeles the attached response:
<br />Affiant deposes and states: That said response is genuine; that the same is not sham or collusive; that all statements of fact therein are true;
<br />that such response was not made in the interest or behalf of any person, partnership, company, association, organization or corporation
<br />not therein named or disclosed.
<br />Affiant deposes and states: That the Responder has not directly or indirectly by agreement, communication or conference with anyone
<br />attempted to induce action prejudicial to the interests of the public body which is to award the contract, or of any other Responder, or
<br />anyone else interested in the proposed contract: that the Responder has not in any manner sought by collusion to secure for itself an
<br />advantage over any other Responder.
<br />Affiant further deposes and states that prior to the public opening and reading of responses the said Responder:
<br />(a) Did not, directly or indirectly, induce or solicit anyone else to submit a false or sham response;
<br />(b) Did not, directly or indirectly, collude, conspire, connive or agree with anyone else that said Responder or anyone else or
<br />fix the response price of said Responder or of anyone else, or to raise or fix any overhead, profit or cost element of its price
<br />or of that of anyone else;
<br />(c) Did not, directly or indirectly, submit its response price or any breakdown thereof, or the contents thereof, or divulge
<br />information or data relative thereto, to any corporation, partnership, company, association, organization, response
<br />depository, or to any member or agent thereof, or to any individual or group of individuals, except to the awarding authority
<br />or to any person or persons who have a partnership or other financial interest with said Responder in its business.
<br />I understand and agree that any falsification in the affidavit will be grounds for rejection of this response or cancellation of any contract
<br />awarded pursuant to this response.
<br />I hereby certify or declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
<br />STATE OF CALF <RNIA N G V4 L) A
<br />COUNTY OF DD"LAS hh
<br />Subscribed and sworn to before me this ' V� day of
<br />(Signature)
<br />pig 6s.IC)87Nr
<br />(Title)
<br />(Date)
<br />l;— to— (k
<br />,,,, ,,,nn..... CONSIDERED UNLESS THE AFFIDAVIT HEREON IS FULLY EXECUTED, INCLUDING THE
<br />•1. MARIE L. CALIBER CERTIFICATE OF THE NOTARY AND THE NOTARIAL SEAL
<br />7 �� Notary Public - State of Nevada t
<br />id ♦ AM~Recorded In WOO oe County
<br />1 No; 020M • 191m Janumy 30,019 F
<br />IMPORTANT — RESPONDERS MUST SUBMIT ALL REQUIRED FORMS (COMPLETELY FILLED OUT) BY RFQ
<br />SUBMITTAL DEADLINE.
<br />Page 101 of 103
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