164-22 Exhibits to Agreement for Workers Compensation Third Party Administration - 2022.pdf

TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITES IN YRAN Proposer: Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or atherwise proposes to enter into or renew a contract must complete the certification below to attest, under penalty of perjury, that the person or entity, or one of the person or entity’s parents, subsidiaries, or affiliates, is not identified on a list created and maintained by the New Jersey Department of the Treasury as ¢ person or entity engaging in investment activities in Iran. [f the Director finds a person or entity to be in violation of the principles which are the subject of this law, s/he shall take action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring, declaring the party in default aad seeking debarment or suspension of the person or entity. I certify, pursuant to Public Law 2012, c. 25, that the person or entity listed above for which I am authorized to submit a proposal: Must check appropriate boxes Is not providing goods or services of $20,000,000 or more in the energy sector of Iran, including a person or entity that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transport oil or [ liquefied natural gas, for the energy sector of Tran, and Is not a financial institution that extends $20,000,000 or more in credit to another person or entity, for 45 days, or more, iF that person or entity will use the credit to provide goods or services in the energy sector in Iran, In the event that a person or entity is unable to make the above certification because it or one of its parents, subsidiaries, or affiliates has engaged in the above referenced activities, a detailed, accurate and precise description of the activities must be provided in part 2 below to the New Jersey Turnpike Authority under penalty of pesjury. Failure to provide such will result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by law. Part 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, acourate and precise description of the activities of the proposer, or one of its parents, subsidiaries or

DE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN You must provide a detailed, acourate and precise description of the activities of the proposer, or one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by completing the boxes below. Naine: Relationship to Proposer: Description of Activities: Duration of Engagement: Anticipated Cessation Date: Proposer Contact Name: Contact Phone Nuaiber: ; Certification: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments i thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above referenced person or entity. I acknowledge that the Township of West Orange, State of New Jersey is relying on the i information contained herein and thereby acknowledge that I am under a continuing obligation trom the date of this certification through the completion of any contracts with the Township to notify the Township in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or | misrepresentation in this certification, and if | do so, I recognize that J am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange, State of New Jersey and that the ‘Township at its option may declare any contract(s) resulting from this certification void and unenforceable, Fall Name (Print): Signature: Title: Date: Hg