181-26 Exhibit A- Final Specifications_compressed.pdf

FEDERAL NON-DEBARMENT CERTIFICATION CERTIFICATION OF NON-DEBARMENT FOR FEDERAL GOVERNMENT CONTRACTS N.J.S.A. 52:32-44.1 (P.L. 2019, c.406) This certification shall be completed, certified to, and submitted to the contracting unit prior to contract award, except for emergency contracts where submission is required prior to payment. PART I: VENDOR INFORMATION Individual or Organization Name Physical Address of Individual or Organization Unique Entity ID (if applicable) CAGE/NCAGE Code (if applicable) Check the box that represents the type of business organization: Sole Proprietorship (skip Parts III and IV) Non-Profit Corporation (skip Parts III and IV) For-Profit Corporation (any type) Limited Liability Company (LLC) Partnership Limited Partnership Limited Liability Partnership (LLP) Other (be specific): ______________________________________________ PART II – CERTIFICATION OF NON-DEBARMENT: Individual or Organization I hereby certify that the individual or organization listed above in Part I is not debarred by the federal government from contracting with a federal agency. I further acknowledge: that I am authorized to execute this certification on behalf of the above-named organization; 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 date of contract award by the 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 that it will constitute a material breach of my agreement(s) with the Township of West Orange permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Full Name

rmitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Full Name Title: (Print): Signature: Date: P-47

PART III – CERTIFICATION OF NON-DEBARMENT: Individual or Entity Owning Greater than 50 Percent of Organization Section A (Check the Box that applies) Below is the name and address of the stockholder in the corporation who owns more than 50 percent of its voting stock, or  of the partner in the partnership who owns more than 50 percent interest therein, or of the member of the limited liability company owning more than 50 percent interest therein, as the case may be. Name of Individual or Organization Physical Address OR No one stockholder in the corporation owns more than 50 percent of its voting stock, or no partner in the partnership owns more  than 50 percent interest therein, or no member in the limited liability company owns more than 50 percent interest therein, as the case may be. Section B (Skip if no Business entity is listed in Section A above) Below is the name and address of the stockholder in the corporation who owns more than 50 percent of the voting stock of the organization’s parent entity, or of the partner in the  partnership who owns more than 50 percent interest in the organization’s parent entity, or of the member of the limited liability company owning more than 50 percent interest in organization’s parent entity, as the case may be. Stockholder/Partner/Member Owning Greater Than 50 Percent of Parent Entity Physical Address OR No one stockholder in the parent entity corporation owns more than 50 percent of its voting stock, no partner in the parent entity partnership owns more than 50 percent interest therein, or no  member in the parent entity limited liability company owns more

ntity partnership owns more than 50 percent interest therein, or no  member in the parent entity limited liability company owns more than 50 percent interest therein, as the case may be. P-48

Section C – Part III Certification I hereby certify that no individual or organization that is debarred by the federal government from contracting with a federal agency owns greater than 50 percent of the Organization listed above in Part I or, if applicable, owns greater than 50 percent of a parent entity of ____________________. I further acknowledge: that I am authorized to execute this certification on behalf of the above- named organization; 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 date of contract award by the Township to notify the Township 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 that it will constitute a material breach of my agreement(s) with the Township permitting the Township to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Title: Signature: Date: Part IV – CERTIFICATION OF NON-DEBARMENT: Contractor – Controlled Entities Section A Below is the name and address of the corporation(s) in which the Organization listed in Part I owns more than 50 percent of voting stock, or of the partnership(s) in which the Organization listed in Part I owns more  than 50 percent interest therein, or of the limited liability company or companies in which the Organization listed above in Part I owns more than 50 percent interest therein, as the case may be. Name of Business Entity Physical Address **Add additional sheets if necessary** OR The Organization listed above in Part I does not own greater than 50 percent of the voting stock in any corporation and does not own greater  than 50 percent interest in any partnership or any limited

s not own greater than 50 percent of the voting stock in any corporation and does not own greater  than 50 percent interest in any partnership or any limited liability company. P-49

Section B (skip if no business entities are listed in Section A of Part IV) Below are the names and addresses of any entities in which an entity listed in Part III A owns greater than 50 percent of the voting stock (corporation) or  owns greater than 50 percent interest (partnership or limited liability company). Name of Business Entity Controlled by Entity Physical Address Listed in Section A of Part IV **Add additional Sheets if necessary** OR No entity listed in Part III A owns greater than 50 percent of the voting stock  in any corporation or owns greater than 50 percent interest in any partnership or limited liability company. Section C – Part IV Certification I hereby certify that the Organization listed above in Part I does not own greater than 50 percent of any entity that that is debarred by the federal government from contracting with a federal agency and, if applicable, does not own greater than 50 percent of any entity that in turns owns greater than 50 percent of any entity debarred by the federal government from contracting with a federal agency. I further acknowledge: that I am authorized to execute this certification on behalf of the above-named organization; 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 date of contract award by Township to notify the Township 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 that it will constitute a material breach of my agreement(s) with the Township permitting the Township to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Title: Signature: Date: P-50

INITIAL PROJECT WORKFORCE REPORT - CONSTRUCTION P-50

w 10. INSTRUCTIONS FOR COMPLETING THE INITIAL PROJECT WORKFORCE REPORT - CONSTRUCTION (AA201) DO NOT COMPLETE THIS FORM FOR GOODS AND/OR SERVICE CONTRACTS Enter the Federal Identification Number assigned to the contractor by the Internal Revenue Service, or if a Federal Employer Identification Number has been applied for but not yet issued, or if your business is such that you have not or will not receive a Federal Identification Number, enter the social security number assigned to the single owner or one partner, in the case of a partnership. Note: The Division of CC/EEO will assign a contractor ID number to your company. This number will be your permanently assigned contractor ID number that must be on all correspondence and reports submitted to this office. Enter the prime contractor’s name, address and zip code number. Check box if Company is Minority Owned or Woman Owned Enter the complete name and address of the Public Agency awarding the contract. Include the contract number, date of award and dollar amount of the contract. Enter the name and address of the project, including the county in which the project is located. . Note: A project contract ID number will be assigned to your firm upon receipt of the completed Initial Project Workforce Report (AA201) for this contract. This number must be indicated on all correspondence and reports submitted to this office relating to this contract. Check “Yes” or “No” to indicate whether a Project Labor Agreement (PLA) was established with the labor organization(s) for this project. Under the Projected Total Number of Employees in each trade or craft and at each level of classification, enter the total composite workforce of the prime contractor and all subcontractors projected to work on the project. Under Projected Employees enter total minority and female employees of the prime contractor and all subcontractors projected to work on the project. Minority employees include Black, Hispanic, American Indian and Asian, (J=Journeyworker, AP=Apprentice). Include projected phase-in and completion dates. Print or type the name of the company official or authorized Equal Employment Opportunity (EEO) official include signature and title, phone number and date the report is submitted. This report must be submitted to the Public Agency that awards the contract and the Division of Contract Compliance and

ial include signature and title, phone number and date the report is submitted. This report must be submitted to the Public Agency that awards the contract and the Division of Contract Compliance and Equal Employment Opportunity in Public Contracts no later than three (3) days after the contractor signs the contract. THE CONTRACTOR IS TO RETAIN THE FOURTH AND FINAL COPY MARKED “CONTRACTOR”, SUBMIT THE THIRD COPY MARKED “PUBLIC AGENCY” TO THE PUBLIC AGENCY AWARDING THE CONTRACT AND FORWARD THE REMAINING TWO (2) COPIES TO: NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF CONTRACT COMPLIANCE & EQUAL EMPLOYMENT OPPORTUNITY IN PUBLIC CONTRACTS P.O. BOX 209 TRENTON, NJ 08625-0209 (609) 292-9550 P-51