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CITY OF SANTA ANA <br />REQUEST FOR PROPOSALS FOR MEDICAL SERVICES REVIEW PROGRAM <br />NON -COLLUSION AFFIDAVIT <br />NON -CO II LUSION AFFIDAVIT <br />(Title 23 United States Code Section 112 and <br />Public Contract Code Section 7106) <br />To the CITY OF SANTA ANA <br />In accordance with Title 23 United States Code. Section 112 and Public Contract Code 7106 the Proposer <br />declares that the proposal is not made in the interest of, or on behalf of, any undisclosed person, partnership, <br />company, association, organization, or corporation; that the proposal is genuine and not collusive or sham; that <br />the Proposer has not directly or indirectly induced or solicited any other Proposer to put in a false or sham <br />proposal, and has not directly or indirectly colluded, conspired, connived or agreed with any Proposer or anyone <br />else to put in a sham proposal, or that anyone shall refrain from bidding; that the Proposer has not in any manner, <br />directly or indirectly, sought by agreement, communication, or conference with anyone to fix the proposal price <br />of the Proposer or any Proposer, or to fix any overhead, profit, or cost element of the proposal price, or of that <br />of any other Proposer, or to secure any advantage against the public body awarding the contract of anyone <br />interested in the proposed contract; that all statements contained in the proposal are true; and, further, that the <br />Proposer has not, directly or indirectly, submitted his or her proposal price or any breakdown thereof, or the <br />contents thereof, or divulged information or data relative thereto, or paid, and will not pay, any fee to any <br />corporation, partnership, company association, organization, bid depository, or to any member or agent thereof <br />to effectuate a collusive or sham proposal. <br />Note: The above non -collusion affidavit is part of the proposal. Signing this proposal on the signature portion <br />thereof shall also constitute signature of this non -collusion affidavit. Proposers are cautioned that making a false <br />certification may subject the certifier to criminal prosecution. <br />State of California, County <br />Subscribed and sworn to (or affirmed) before me on this day of 20_, by <br />, proved to me on the basis of satisfactory evidence to be the person(s) who <br />appeared before me. <br />Notary Public Signature <br />Notary Public Seal <br />THIS FORM MUST BE COMPLETED AND INCLUDED WITH THE PROPOSAL. <br />PROPOSALS THAT DO NOT CONTAIN THIS FORM WILL BE CONSIDERED NONRESPONSIVE. <br />EXHIBIT I <br />City of Santa Ana Human Resources Department <br />RFP for Medical Services Review—August 27, 2018 <br />26E -2S3 <br />