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<br /> <br /> <br />EXHIBIT E-4 <br /> <br />ANTI-KICKBACK STATEMENT <br /> <br />CITY OF EUGENE <br /> <br />CAPITAL IMPROVEMENT PROGRAM <br /> <br /> <br />TO: <br /> City of Eugene Capital Improvement Program <br /> <br />RE: <br /> Project <br /> <br /> <br />DATE: <br /> XX/XX/XXXX <br /> <br /> <br />The undersigned contractor certifies that: <br /> <br />1. The total contract price is for only those items listed on the Work Write-Up, and none other; <br /> <br />2. There has not been, and will not be, any kickbacks, credit or other similar payment in any <br />form made to the owner or any other person; <br /> <br /> <br /> <br />CONTRACTOR Name: <br /> <br /> <br />CONTRACTOR SIGNATURE: <br />______________________________________________ <br /> <br /> Sign & Print <br /> <br /> <br /> <br />ATTEST: <br />______________________________________________________ <br /> Sign & print name <br /> <br /> ______________________________________________________ <br /> Sign & print name <br /> <br />Prime Contractor to complete <br /> <br /> <br />