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NON - COLLUSIVE AFFIDAVIT State of )ss County of deposes and says that: being first duly sworn, (1) He /she is the Owner, Partner, Officer, Representative or Agent of the Bidder that has submitted the attached Bid; (2) He /she is fully informed respecting the preparation and contents of the attached Bid and of all pertinent circumstances respecting such Bid; (3) Such Bid is genuine and is not a collusive or sham Bid; (4) Neither the said bidder nor any of its officers, partners, owners, agents, representatives, employees or parties in interest, including this affiant, have in any way colluded, conspired, connived or agreed, directly or indirectly, with any other Bidder, firm, or person to submit a collusive or sham Bid in connection with the Work for which the attached Bid has been submitted; or to refrain from bidding in connection with such Work; or have in any manner, directly or indirectly, sought by agreement or collusion, or communication, or conference with any Bidder, firm, or person to fix the price or prices in the attached Bid or of any other Bidder, or to fix any overhead, profit, or cost elements of the Bid price or the Bid price of any other Bidder, or to secure through any collusion, conspiracy, connivance, or unlawful agreement any advantage against the City of Sunny Isles Beach, or any person interested in the proposed Work; (5) The price or prices quoted in the attached Bid are fair and proper and are not tainted by any collusion, conspiracy, connivance, or unlawful agreement on the part of the Bidder or any other of its agents, representatives, owners, employees or parties in interest, including this affiant. Sworn to and subscribed before me this day of , 2001, by who is personally known to me or has provided as identification. Notary Seal: -14— Health Insurance Proposal 2001 Notary Signature