Township Council Meeting — Packet

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