Township Council Meeting — Packet

MENT 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: Cu STOoM Pa o tect 4 Seaui ce§ CCC Organization Address: 25S Lex IW/ANCNA iN New fon. Nv joo\?7 Part I Check the box that represents the type of business organization: Dsoie Proprietorship (skip Parts I! and III, execute certification in Part IV) oO Non-Profit Corporation (skip Parts I! and.Il!, execute certification in Part IV) oO For-Profit Corporation (any type) Limited Liability Company (LLC) oO Partnership oO Limited Partnership Oo Limited Liability Partnership (LLP) Dlother (be specific): Part IT 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 Oo 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 Seok MABER 36( Highview oto Englewood NS 6763 ( 18|Page

Part IIT DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART It 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 Il other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate 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 I 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, | am subject to criminal prosecution under the law and

ained herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, | am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, 19|Page

permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Rebent Wa Title: Vite Resoe- Signature: (Cork Wis Date: V >) \>3 20|Page

REQUIRED EVIDENCE AFFIRMATIVE ACTION REGULATIONS NJ. S.A. 10:5-31, et seq. (N,LA. C. 17:27) If awarded a contract, the Bidder will be required to comply with the requirements of N.[.S.A. 10:531, et seg., and N.LA.C 17:27. Within five (5) days after receipt of the notification of intent to award the contract, the Bidder shall present one of the following: 1. Appropriate evidence that the Contractor is operating under an existing federally approved or sanctioned affirmative action program; or 2. A Certificate of Employee Information Report Approval issued in accordance with NLA. 17:27-4; or 3. An initial Employee Information Report consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with N.LA.C. 17:27-4. The Bidder must submit no later than three (3) days after the signing of the Contract an Initial Project Manning Table consisting of forms provided by the Affirmative Action Office and completed by Contractor in accordance with N.L.A.C. 17:27-7. Bidders are referred to the Bidder's Information Section of the Bid Packet for a further description of the above requirements. NO BIDDER MAY BE ISSUED A CONTRACT UNLESS THEY COMPLY WITH THE AFFIRMATIVE ACTION REGULATIONS OF N.J.S.A. 10:5-31, et seq. ‘The following questions must be answered by all Bidders: il Do you have a federally-apptoved or sanctioned Affirmative Action Program? Yes (f yes, submit a copy of such approval.) No 2. Do you have a State Certificate of Employee Information Repott approval? Yes {If yes, submit a copy of such approval.) No The undersigned Bidder certifies that he is aware of the commitment to comply with the requirements of N.J.S.A. 10:5-31, et seq., and agrees to furnish the requi‘ed documentation pursuant to the law. company: Custom Probe hve SeayceSname: SIGNATURE: ku Wise rip: VILE (AES 02a NOTE:A bid must be rejected as non-responsive if a Bidder fails to comply with requirements of NJS.A. 10:5-31, et seq., within stipulated time. 16|Page

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[Prohibited Russia-Belarus Activities & [ran Investment Activities L I Person or Entity Custom Pro deahye Senuic?s Part 1: Certification OMPLETE PART | BY CHECKING QNE OF THE THREE BOXES BELOW Pursuant to law, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, for goods or services must complete the certification below prior to contract award to lattest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate, is identified on the Department of Treasury's Russia-Belarus list or Chapter 25 list as a person or| lentity engaging in prohibited activities in Russia, Belarus or Iran. Before a contract for goods or services can lbe amended or extended, a person or entity must certify that neither the person or entity, nor any parent entity, subsidiary, or affiliate, is identified on the Department of Treasury's Russia-Belarus list. Both lists are found! n Treasury’s website at the following web addresses: https://www.nj.gov/treasury/administration/pdf/RussiaBelarusEntityList.pdf Iwww.state.nj.us/treasury/purchase/pdf/Chapter25 List.pdf. |As applicable to the type of contract, the above-referenced lists must be reviewed prior to completing the below certification. JA person or entity unable to make the certification must provide a detailed, accurate, and precise description f the activities of the person or entity, or of a parent entity, subsidiary, or affiliate, engaging in prohibited lactivities in Russia or Belarus and/or investment activities in Iran. The person or entity must cease engaging, in any prohibited activities and provide an updated certification before the contract can be entered into. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may be rovided 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. {CONTRACT AWARDS AND RENEWALS certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate appears on the N.J. Department of Treasury’s lists of entities engaged in prohibited activities in Russia or Belarus pursuant to P.L. 2022, c. 3 or in investment activities in

subsidiary, or affiliate appears on the N.J. Department of Treasury’s lists of entities engaged in prohibited activities in Russia or Belarus pursuant to P.L. 2022, c. 3 or in investment activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or ‘epresentative of the entity listed above and am authorized to make this certification on its behalf. (Skip Part 2 and sign and complete the Certification below.) 21|Page

|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

Township of West Orange Court Security Specifications Part 3: Certification of True and Complete Information /, being duly sworn upon my oath, hereby represent and state that the foregoing information and any ttachments there, to the best of my knowledge, are true and complete. I attest that I am authorized to execute his certification on behalf of the above-referenced person or entity. {/ acknowledge that the Township of West Orange is relying on the information contained herein and hereby knowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Township of West Orange to notify the Township of West Orange in writing of any changes to the answers of information contained herein. |! acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Township of West Orange and that the Township of West Orange at its option may declare any contract(s) resulting from this certification void fand unenforceable. Prine Robent fe Wist Title Tice PrRegepenT Signature (Cal) Wine Date 2] ‘ | a> 23|Page