295-24 Exhibit.pdf

STATEMENT OF OWNERSHIP DISCLOSURE N.JS.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Organization Address: Part Check the box that represents the type of business organization: DI sote Proprietorship (skip Parts I! and Hil, execute certification in Part IV) DAnon-Profit Corporation (skip Parts Il and Ill, execute certification in Part IV) Oo For-Profit Corporation (any type) O Limited Liability Company (LLC) Dl partnership Dlhimitea Partnership Diimitea Liability Partnership (LLP) other (be specific): Part ll oO The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR | No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART Iv) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity Address

Part Ill DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART II If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial Interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed. Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part i other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every non-corporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24,2 has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Address Corresponding Entity Listed in Part Il Part IV Certification |, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | acknowledge: that | am authorized to execute this certification on behalf of the bidder/proposer; that the Township of West Orange is relying on the information contained herein and that | am under a continuing obligation from the date of this certification through the completion of any contracts with Township of West Orange to notify the Township of West Orange in writing of any changes to the information contained herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if |do so, lam subject to criminal prosecution under the law and

ntained herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if |do so, lam subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. 23|Page

Title: Date: Full Name (Print): Signature: 24| Page

TOWNSHIP OF WEST ORANGE DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN Proposer: Pursuant to Public Law 2012, c, 25, any person or entity that submits a bid or proposal or otherwise 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 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 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 and 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 | am authorized to submit a proposal: Must check appropriate boxes (1 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 Iran, and C1 ts nota 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 perjury. 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, accurate 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, 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 Proposer: Description of Activities: Duration of Engagement: Anticipated Cessation Date: Proposer Contact Name: Contact Phone Number: Certification: |, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | attest that | am authorized to execute this certification on behalf of the above referenced person or entity. | acknowledge that the Township of West Orange, State of New Jersey is relying on the information contained herein and thereby acknowledge that | am under a continuing obligation from 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. | acknowledge that | am aware that it is a criminal offense to make a false statement or misrepresentation in this 25|Page

certification, and if | do so, | recognize that | 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. Full Name (Print): Signature: Title: Date: } | i i

: ‘ TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: Please assign the number, date and initial. Addendum Number Dated Acknowledge Receipt (Initial) (No addenda was/were received. Acknowledged for: (Company Name) By: (Signature of Authorized Representative) Name: (Print) Title: Date: 27|Page

: f INSURANCE REQUIREMENTS AND ACKNOWLEDGEMENT FORM Certificate(s) of Insurance shall be filed with the Municipal Clerk's Office upon award of contract by the Mayor and Township Council. The minimum amount of insurance to be carried by the Professional Service Entity shall he as follows: PROFESSIONAL LIABILITY INSURANCE Limits shall be a minimum of $1,000,000.00 for each claim and $1,000,000.00 aggregate each policy period. Acknowledgement of Insurance Requirement: (Signature) (Date) (Printed Name and Title) 28|Page

i b 1 q AMERICANS WITH DISABILITIES ACT OF 1990 Eqnal Opportunity for Individuals with Disability The contractor and the Township of West Orange, (hereafter "TOWNSHIP") do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "Act") (42 U.S.C. $121 01 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the TOWNSHIP pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the TOWNSHIP in any action or administrative proceeding commenced pursuant to this Act. The contractor shall indemnify, protect, and save harmless the TOWNSHIP, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind of nature arising out of or claimed to arise out of the alleged violation. The contractor shall, at its own expense, appear, defend, and pay any and all charges for lega! services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the TOWNSHIP's grievance procedure, the contractor agrees to abide by any decision of the TOWNSHIP which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the TOWNSHIP, or if the TOWNSHIP incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the contractor shall satisfy and discharge the same at its own expense. The TOWNSHIP shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim, if any action or administrative proceeding is brought against the TOWNSHIP or any of its agents, servants, and employees, the TOWNSHIP shall expeditiously forward or