Township Council Meeting — Packet

all 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 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 H no later than 10 days prior to the award of the contract. Part I - Vendor Information Vendor Name: | Address: | City: | | State: l 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.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. CD Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount $

| | Continuation Page C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Page__ of Vendor Name: Required Pursuant To N.J.S.A. 19:44A-20.26 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 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-Maplewaod Verona Borough West Essex Regional West Orange Town Fire Districts (Board of Fire Commissioners): NONE

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