205-26 Exhibit.pdf

C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Contractor Instructions Business entities (contractors).receiving contracts from a public agency that are NOT awarded pursuant to a “fair and open” process (defined at N.I.S.A. 19:44A-20.7) are subject to the provisions of N.LS.A. 19:44A-20.26. This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contributions to: * any continuing political committee (a.k.a., political action committee) * any candidate committee of a candidate for, or holder of, an elective office: o ofthe public entity awarding the contract o of that county in which that public entity is located oof another public entity within that county o of of a legislative district in which that public entity is located or, when the public entity is a county, of any legislative district which includes all or part of the county The disclosure must list reportable contributions to any of the committees that exceed $200 per election cycle that were made during the 12 months prior to award of the contract. See N.J.S.A. 19:44A-8 and 19:44A-16 for more details on reportable contributions. N.LS.A. 19:44A-20.26 itemizes the parties from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: ¢ individuals with an “interest” ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit ¢ all principals, partners, officers, or directors of the business entity or their spouses * any subsidiaries directly or indirectly controlled by the business entity © IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business entity and filing as continuing political committees, (PACs). When the business entity is a natural person, “a contribution by that person’s spouse or child, residing therewith, shall be deemed to be a contribution by the business entity.” [N.J.S.A, 19:44A-20.26(b)] The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall be subject to a fine imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist

fine imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist the contractor in identifying those public agencies whose elected official and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor’s responsibility to identify the specific committees to which contributions may have been made and need to be disclosed, The disclosed information may exceed the minimum requirement. The enclosed form, a content-consistent facsimile, or an electronic data file containing the required details (along with a signed cover sheet) may be used as the contractor’s submission and is disclosable to the public under the Open Public Records Act. The contractor must also complete the attached Ownership Disclosure Certification. This will assist the agency in meeting its obligations under the law. NOTE: This section does not apply to Board of Education contracts.

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 | — 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 Il - Contribution Disclosure Disclosure requirement: Pursuant to N..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. OO Cheek here if disclosure is provided in electronic form, Contributor Name Recipient Name Date Dollar Amount $

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

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 Sheriff County Executive Surrogate Registrar of Deeds Municipalities (Mayor and members of governing body, regardless of title): Belleville Township Irvington Township Orange City Bloomfield Township Livingston Township Roseland Borough Caldwell Borough Maplewood Township South Orange Village Cedar Grove Township Millburn Township Verona Township East Orange City Montclair Township West Caldwell Township Essex Fells Township Newark City West Orange Township Fairfield Township North Caldwell Borough Glen Ridge Borough Nutley Township Boards of Education (Members of the Board): Belleville Town, Bloomfield Township Caldwell-West Caldwell Cedar Grave 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

f ' 1 | STATEMENT OF OWNERSHIP DISCLOSURE NLLS.A, 52:25-24.2 (P.L. 1977, 0.33, as amended by P.L. 2016, ¢.43) This statement shall be completed, certified to, aud 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: Oo Sole Proprietorship (skip Parts II and UJ, execute certification in Part IV) Cd non-profit Corporation (skip Parts I and II, execute certification in Part IV) O For-Profit Corporation (any type) Phiimites Liability Company (LLC) | Partnership | Limited Partnership Limited Liability Partnership (LLP) Dotter (be specific): Part 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 mote 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 III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART IT Ifa 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 annua! 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 annua! 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 SI 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.LS.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 II 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. | 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 faise statement or misrepresentation in this certification, and if I do so, I] am subject to criminal prosecution under the law and

ined herein; that I am aware that it is a criminal offense to make a faise 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. Page | 29

Title: Date: Full Name (Print): Signature: Page | 30

CERTIFICATION OF NON-INVOLVEMENT IN PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS Pursuant to NJ.S,A, 62:32-60.1, et seq (L, 2022, c, 3) arly person or eiity {hereitiafler "Vendor") thal seeks to shite into or ranev-a contract with a State agenay forthe provision of goods or services, or the purchase of bonds or othst obligations, must complete the certification below indicating whether or ict. the Vendor ‘s ‘identified on the Office of Foreign Assets tro) FAC) Specially Designated Nationals and Blocked Persons. isl, vallable Here: e [the Department of the Treasury finds that a Vendor has made. a certification in ‘Woletion of tha law, it shall take ‘any action'as may be appropriate and provided by law, rulé or contract, including but not lifted to, linposing sanétions, Seeking compliance, recovering damages, declaring the party if default aid seeking dabarmant orsuspeasion of the party. |, fie undersigned, ceitify Hist | have reed the definition of “Varitor" bélow, and have raviewed the Offica of Foreign Assets Cortrol (OFAG): Specially Designated Nationals and Blocked Persons list, and having dangesa certify: (Ghetk the Appropriate Box) 4, thatthe Vendor is not ideniified on the FAG. Spa oO gosddunt of adlivity related to Russta and/or Belarus, OR p, ‘That lam unable to certify as-to “AY above, bocause the Vendor is identified on the OFAC Spésially OQ * Desianated Nationals shd Blocked Persons list onl acount of nctivity related to Russia andor Belarus, ‘OR ‘That |-em uneble to certify as to “A shove, becausé the Vendor is Idefttified on ihe ofa Sbecially ) <. ‘Desiqnated Nationals:and Blocked Persons list. Hewever, the: Vendor is engaged Inactivily related to Russia " and/or Belanis nonsistent with federal law, regulation, license er-exemption. A detailed description of how the Vendor's activity related fo Russia and/or Belarus is: consistent with federal jaw is set forth below. (Aitanti Adtilianal Shoots if Necossay) ‘Signature oF Vendor's Authorized Representative Bate PriitNarne and Tike of Veridrs Authorized Reprocuntabve, Vendors FEIN ‘Vendor's Name Vendors Prone Number Vendors Address (Sirset Address} Vendor's Bax Number Vendor's Address (GiiiStatelZip Gade) ‘Vendors Emall Address | Wendor means: (1) A-netural person, corporation, company, lined partnership, limited ilablily partnership, limited Nablity company; bushesy-nssoclation, sole