293-22 Exhibit A.pdf

Article 3.19 TOWNSHIP OF WEST ORANGE DfSCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer: 11..ibL.tJ.\-l'.>L..t v>voD f RD!ML-15;. LLC... 1 Pursuant to Public La\v 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter into or renev·i 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 Ne\.v Jersey Department of the Treasury as a person or entity engaging in investment activities in Iran. If the Director finds a person or entity to be in violation of the principles ..vhich 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 lirn ited to, imposing sanctions, seeking compliance, recovering damages, declaring, declaring the party in default and seeking debarment or suspension of the person or entity. I certify, pursuant to Public Lan• 2012, c. 25, that the person or entity listed above fo1· n'hich l am authorized to submit a proposal: l\1ust check appropriate boxes ~ ls not providing goods or services of S20,000,000 or more in the energy sector of lran, including a person or entity that provides oil or liquefied natural gas tankers, or products used to construct or maintain pipelines used to transpo1t oi I or liquefied natural gas, for the energy sector of Iran, and 0 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 \viii use the credit to provide goods or services in the energy sector in Iran. Jn 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 belov.• to the Ne\v Jersey Turnpike Authority under penalty of perjury. Failure to provide such \Viii result in the proposal being rendered as non-responsive and appropriate penalties, fines and/or sanctions will be assessed as provided by

hority under penalty of perjury. Failure to provide such \Viii 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 JN FORMATION RELATED TO INVESTMENT ACTlVITlES IN !RAN You must pro\•ide a detailed, accurate 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. Name:~-~~-,.,---------- Relationship to P r o p o s e r : - - - - - - - - - - Description of A c t i v i t i e s : - - - - - - - - - - - - - - - - - - - - - - - - - - - Duration of Engagement·. _ _ _ _ _ _ _ _ _ Anticipated Cessation Date: _ _ _ _ _ _ _ __ Proposer Contact Name: Contact Phone N u m b e r : - - - - - - - - - - CertiFication: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any auachments thereto to the best of my knowledge ;:ire true and complete. I attest that I am authorized to execute this certification on beha!fofthe above referenced person or entity. ! acknowledge that the Township of West Orange, Stntc of New Jersey is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any conmlcts with the Township to notify the To\vnship in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is n criminiil ofTense to make a false statement or misrepresentation in this certification, and if! do so, I recognize that ! am subject to criminal -.· prosecution under the law and that it will also constitute a material bre;ich of my agreement(s) with the Township of\Ves! Orange, State of New Jersey and that the Township at its option may declare any contract(s) resulting from this certification void and unenforceable. _;;,,->~ //~ Ful!Name(Print): /;~e.ne. <!'..11>-r)Lcw.sl.q. Signature:::\.~4~~ -- //- Title: 1,h e rs- iV-es 1p-enI

>~ //~ Ful!Name(Print): /;~e.ne. <!'..11>-r)Lcw.sl.q. Signature:::\.~4~~ -- //- Title: 1,h e rs- iV-es 1p-enI Date: '?'/t.7-f 8 ' I 56