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A. This proposal, bid or contract is made without any connection or common interest in the <br /> profits with any other person other than the Service Providers except as listed on a <br /> separate attached sheet to this affidavit. <br /> Check One: <br /> Others Interested in Contract X None <br /> D.No department director or any employee or any officer of the City of Champaign has any <br /> financial interest, directly or indirectly, in the award of this contract except as listed on a <br /> separate attached sheet to this affidavit. <br /> E.That the Service Provider is not barred from bidding on any contract as a result of violation of <br /> 720 ILCS 5/33E-3 and 5/33E-4 (Bid Rigging or Bid Rotating). <br /> SECTION Ill. DRUG FREE WORKPLACE AND DELINQUENT ILLINOIS TAXES STATEMENT <br /> The undersigned states under oath that the Service Provider is in full compliance with the Illinois <br /> Drug Free Workplace Act, 30 ILCS 580/1, et. seq. The undersigned also states under oath and <br /> certifies that the Service Provider is not delinquent in payment of any tax administered by the <br /> Illinois Department of Revenue except that the taxes for which liability for the taxes or the <br /> amount of the taxes are being contested in accordance with the procedures established by the <br /> appropriate Revenue Act; or that the Service Provider has entered into an agreement(s) with the <br /> Illinois Department of Revenue for the payment of all taxes due and is in compliance with the <br /> agreement. (65 ILCS 5/11-42.1-1) <br /> SECTION IV. FAMILIARITY WITH LAWS STATEMENT <br /> The undersigned, being duly sworn, hereby states that the Service Provider and its employees <br /> are familiar with and will comply with all Federal, State and local laws applicable to the project, <br /> which may include, but is not limited to, the Prevailing Wage Act and the Davis-Bacon Act. <br /> SERVICE PROVIDER <br /> Hasselberg, Williams, Grebe, S o grass & Birdsall <br /> By: <br /> Signature <br /> David L. Wentworth II <br /> Printed Name <br /> Partner <br /> Title <br /> SUBSCRIBED and SWORN to before me this JCw lay of 20kL��_ <br /> FKRANE <br /> wwrw---- r+� <br /> N tary Public �IL�- <br /> L MONTGOMERY <br /> 1 UBLIC-STATE OF ILLINOIS <br /> MIMON EXPIRES:10107/13 <br />