115-25 Proposal - CPS.pdf

|CONTRACT AMENDMENTS AND EXTENSIONS ¢ certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate is listed on the N.J. Department of the Treasury’s lists of entities determined to be engaged in prohibited activities in Russia or Belarus pursuant to P.L. 2022, c. 3. I further certify that I am the person listed above, or Iam n officer or representative of the entity listed above and am authorized to make this lcertification on its behalf. (Skip Part 2 and sign and complete the Certification below.) IF UNABLE TO CERTIFY oO part : Additional Information am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate is listed on the Department's Russia-Belarus list and/or Chapter 25 Iran list. will provide a detailed, accurate, and precise description of the activities las directed in Part 2 below, and sign and complete the Certification below. Failure to wovide such will prevent the award of the contract to the person or entity, and appropriate penalties, fines, and/or sanctions will be assessed as provided by law. PLEASE PROVIDE FURTHER INFORMATION RELATED TO PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS AND/OR INVESTMENT ACTIVITIES IN IRAN. You must provide a detailed, accurate, and precise description of the activities of the person or entity, or of a parent entity, subsidiary, or affiliate, engaging in prohibited activities in Russia or Belarus and/or investment activities in Iran in the space below and, if needed, on additional sheets provided by you. 22|Page