99-24 Exhibit to Temporary Extension Agreement.pdf

Name: _________________________ Name: Relationship to Relationship to Proposer: Proposer: _______________________ Description of Description of Activities: Activities: ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Duration of Duration of Engagement: Engagement: ____________________ Anticipated Anticipated Cessation: Cessation: __________________ Date: _____________________ Date: Proposer Contact Proposer Contact Name: Name: _____________________ Contact Contact Phone: Phone: _______________________ Number: ________________________ Number: Certification: I,I, being Certification: being dulyduly sworn sworn upon upon my my oath, oath, hereby hereby represent represent and and state state that that the the foregoing foregoing information and information and any any attachments attachments thereto thereto to to the the best

ts attachments thereto thereto to to the the best best of of my my knowledge knowledge are are true true and and complete. complete. I| attest that attest that I| am am authorized authorized to to execute execute this this certification certification on on behalf behalf ofof the the above above referenced referenced personperson or entity. or entity. II acknowledge acknowledge that that the the Township Township of of West West Orange, Orange, StateState ofof New New Jersey Jersey is is relying

New Jersey Jersey is is relying relying onon the the information contained information contained hereinherein and and thereby thereby acknowledge acknowledge that that I| am am under under aa continuing continuing obligation obligation from the from the date date of of this this certification certification through through the the completion completion of of any any contracts contracts with the Township with the Township to to notify the notify the Township Township in in writing writing ofof any any changes changes to to the the answers answers of of information

the answers answers of of information information contained contained herein. herein. I| acknowledge that acknowledge that I| am am aware aware that that it it is is aa criminal criminal offense offense to to make make aa false false statement statement or or misrepresentation in misrepresentation in this this certification, certification, and and if if II do do so, so, I| recognize recognize that that I1 am am subject subject to to crin1inal crinlinal prosecution under prosecution under thethe law law and and that

crinlinal prosecution under prosecution under thethe law law and and that that itit will will also also constitute constitute aa material material breach breach ofof my my agreement(s) agreement(s) with the Township with the Township of of West West Orange, Orange, State State of of New New Jersey Jersey andand that that the the Township Township at at its its option option may may declare any declare any contract(s) contract(s) resulting resulting from from thisthis certification certification void

resulting from from thisthis certification certification void void and and unenforceable. unenforceable. Full Name Full Name (Print): (Print): _________________________ Signature: Signature: _______________________ Title: _________________________ Title: Date: _____________________________ Date: 56 56