238-25 Exhibit A to Agreement for Snow Removal Services - 2025.pdf

C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 This form or its permitted facsimile must be submitted to the local unit no later than 10 days prior to the award of the contract. Part I – Vendor Information Vendor Name: Address: City: State: Zip: The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this form. _________________________ ____________________________ _________________________ Signature Printed Name Title Part II – Contribution Disclosure Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contributions (more than $200 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided by the local unit.  Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount $ 15

Continuation Page C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 Page ___ of ______ Vendor Name: Contributor Name Recipient Name Date Dollar Amount $ 16

List of Agencies with Elected Officials Required for Political Contribution Disclosure N.J.S.A. 19:44A-20.26 County Name: Essex State: Governor Legislative District #s: 26, 27, 28, 29, 34, & 40 State Senator and two members of the General Assembly per district. County: County Commissioners County Clerk County Executive Surrogate Sheriff Registrar of Deeds Municipalities (Mayor and members of governing body, regardless of title): Belleville Township Bloomfield Township Caldwell Borough Cedar Grove Township East Orange City Essex Fells Township Fairfield Township Glen Ridge Borough Irvington Township Livingston Township Maplewood Township Millburn Township Montclair Township Newark City North Caldwell Borough Nutley Township Boards of Education (Members of the Board): Belleville Town Bloomfield Township Caldwell-West Caldwell Cedar Grove Township Essex Fells Borough Fairfield Township Glen Ridge Borough Irvington Township Livingston Township Millburn Township Newark City North Caldwell Borough Nutley Town Roseland Borough South Orange-Maplewood Verona Borough West Essex Regional West Orange Town Fire Districts (Board of Fire Commissioners): NONE 17 Orange City Roseland Borough South Orange Village Verona Township West Caldwell Township West Orange Township

STATEMENT OF OWNERSHIP DISCLOSURE N.J.S.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 I Check the box that represents the type of business organization: Sole Proprietorship (skip Parts II and III, execute certification in Part IV) Non-Profit Corporation (skip Parts II and III, execute certification in Part IV) For-Profit Corporation (any type) Limited Liability Company (LLC) Partnership Limited Partnership Limited Liability Partnership (LLP) Other (be specific): ______________________________________________ Part II 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 18

Part III 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 II 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 Corresponding Entity Listed in Part II Address Part IV Certification I, 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. I acknowledge: that I 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 I 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 I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and

ained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am 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. Full Name (Print): Title: Signature: Date: 32

BUSINESS REGISTRATION CERTIFICATION AND PUBLIC WORKS CONTRACTOR REGISTRATION CERTIFICATION Effective September 1, 2004, the State has expanded its Contractor Registration Program to local Government contracts, P.L. 2004, c57. All business organizations that do business with a local government agency are required to be registered with the State. The business must provide proof of that registration to the local government agency before that local government agency can enter into a contract with the business. A copy of the Business Registration Certificate must also be on file before any purchase order/voucher or other contracting document can be issued. Contractors are responsible for notifying subcontractors. Further information and registration can be obtained online from the NJ Treasury, Division of Revenue or by calling (609) 292-1730. ************************ P.L. 1999 Chapter 238. The Public Works Contractor Registration Act specifies that no contractor or subcontractor shall bid on or engage in any contract (or part thereof) for public work which is subject to the provisions of the "New Jersey Prevailing Wage Act", P.L. 1963 C. 150 (c. 34:11-56.25 et seq.) for the construction, reconstruction, demolition, alteration, repair, or maintenance of a public building regularly open to and used by the general public or public institution, and includes any subcontractor or lower tier subcontractor of a contractor unless they are registered with the Commissioner of Labor. 33

ay CERTIFICATION OF NON-INVOLVEMENT IN Ss PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS. Pursuant to N.J.S.A. 52:32-60.1, et seq. (L_ 2022, c. 3) any person or entity (hereinafter “Vendor") that seeks to enter into or renew a contract with a State agency for the provision of goods or services, or the purchase of bonds or other obligations, must complete the certification below indicating whether or not the Vendor is identified on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, available _here https://sanctionssearch.ofac.treas.gow/. If the Department of the Treasury finds that a Vendor has made a certification in violation of the law, it shall take any action as may be appropriate and provided by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages, declaring the party in default and seeking debarment or suspension of the party. |, the undersigned, certify that | have read the definition of “Vendor” below, and have reviewed the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, and having done so certify: (Check the Appropriate Box) account of activity related to Russia and/or Belarus. O A That the Vendor is not identified on the OFAC Specially Designated Nationals and Blocked Persons list on OR B That | am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially ®) "Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus. OR That | am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially O c. Designated Nationals and Blocked Persons list. However, the Vendor is engaged in activity related to Russia and/or Belarus consistent with federal law, regulation, license or exemption. A detailed description of how the Vendor's activity related to Russia and/or Belarus is consistent with federal law is set forth below. (Attach Additional Sheets If Necessary.) Signature of Vendor's Authorized Representative Date Print Name and Title of Vendor's Authorized Representative Vendor's FEIN Vendor's Name Vendor's Phone Number Vendor's Address (Street Address) Vendor's Fax Number Vendor's Address (City/State/Zip Code) Vendors Email Address ‘ Vendor means: (1) A natural person, corporation, company,

me Vendor's Phone Number Vendor's Address (Street Address) Vendor's Fax Number Vendor's Address (City/State/Zip Code) Vendors Email Address ‘ Vendor means: (1) A natural person, corporation, company, limited partnership, limited liability partnership, limited liability company, business association, sole proprietorship, joint venture, partnership, society, trust, or any other nongovernmental entity, organization, or group; (2) Any governmental entity or instrumentality of a government, including a muitilateral development institution, as defined in Section 1701(c)(3) of the International Financial Institutions Act, 22 U.S.C. 262r(c)(3); or (3) Any parent, successor, subunit, direct or indirect subsidiary, or any entity under common ownership or control with, any entity described in paragraph (1) or (2) NJ Rev. 1.22.2024 34

SITE INSPECTION AFFIDAVIT I, ____________________________, on behalf of the bidder, __________________________, do hereby declare that, I or my duly authorized representative, did satisfactorily inspect the project limits for the purpose of being fully informed as to the locations and conditions of the various Sidewalks, Paths, Crosswalk and Bus Shelters and Stops within the Township of West Orange for snow removal to be cleared under this contract. I inspected the various sites on the ______ day of_______________, ________, and I hereby acknowledge that I have satisfied myself regarding the conditions of the various sites and the nature and extent of the work to be performed under this contract. By________________________________ (Print or type name) ________________________________ (Bidding Firm/Contractor) Subscribed and sworn to Sworn before me this ____ day of __________ 20_____. ______________________________ (Notary Public) My commission expires on ______________, __________. 35