Township Council Meeting — Packet

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 oO in Part IIl 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 in any corporation or owns greater than 50 percent interest in any “a No entity listed in Part II] A owns greater than 50 percent of the voting stock partnership or limited liability company. Section C — Part IV Certification Il hereby certify that the Organization listed above in Part | 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. | further acknowledge: that | 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 | 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 | 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 Township permitting the Township to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): a Title: Se. - Signature: “> Date: L [22 hae, P-50

INITIAL PROJECT WORKFORCE REPORT - CONSTRUCTION Official Use Only STATE OF NEW JERSEY Assignment DIVISION OF CONTRACT COMPLLANCE EQUAL EMPLOYMENT OPPORIUNITY IX PUBLIC CONTRACTS rade FORMAL Revived 1683 READ INSTRUCTION. PLEASE TYPE OR PRINT IN BLACK OR BLUE INK. T FID NUMBER FA CONTRACTOR ID NUMBER INITIAL PROJECT WORKFORCE REPORT CONSTRUCTION 3 NAME AND ADDRESS OF PUBLIC AGENCY AWARDING CONTRACT ‘3. NAME AND ADDRESS OF PRIME CONTRACTOR nao CONTRACT NUMBER DATE OF AWARD DOLLAR AMOUNT OF AWARO Gi aaron) WANE AND ADDRESS OF PROUEGT FT FROHCTNOGER teh) ea (iy Cote lcounry 1s THis PROJECT COVERED BY A PROJEX 4, 1S THIS COMPANY MINORITY OWNED [ ] OR WOMAN OWNED LABOR AGREEMENT (PLA)? DYES ONC TRADE OR CRAFT PROJECTED MINORITY EMPLOVEES| PROJECTED PROJECTED rt rkask-18 | COMPLETION DATE DATE 1, ASBESTOS WORKER 2, BRICKLAYER OR MASON 3. CARPENTER _ 4, ELECTRICIAN 5. GLAZIER 6, HVAC MECHANIC = | 7, IRONWORKER 8. OPERATING ENGINEER 9. PAINTER, 10. PLUMBER ll. ROOFER 12. SHEET METAL WORKER 13. SPRINKLER FITTER 14. STEAMFITTER 15. SURVEYOR 16_ TILER 17. TRUCK DRIVER 18. LABORER 19. OTHER 20. OTHER i. = ‘Thereby cerify thar the foregoing statements made Dy ine are true, Tam aware thatit any of Ue foregomg Tatements are wilfully false, I am subject to punishment. (Signature) Te, (lence Print Your Name) ie (Area Code) (Telephone Number) Ext.) Dare P-50

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 vet 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 parmership. 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 bos 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 vour 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. 10. 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 Equal

clude 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- (609) 292-9: 0209 P-51

FORM W-9 Request for Taxpayer W-9 Give Form to the (Rev. October 2018) Identification Number and Certification requester. Do not Department of the Treasury ‘send to the IRS. internal Revenue Service > Go to www.irs.gov/FormW9 for instructions and the latest information. 1 Name fas shown on your income tax retum). Name is requred on this |ine; do not leave this line blank. Basie narneld regarded erly name, ¥ Garant rom above 3 Check appropriate box fo federal tax clasifcaton ofthe person whose nares ewered on tne 4 Check nly one ofthe | 4 Exemlions (codes apply only to following seven boxes. D1 indivduatsote proprietor or single-member LLC LLC the LLC is classified as a single-momber LLG that another LLC that is not cisregarced from the owner for [Ly other (see instructions) » OO ccomoration 1) s Corporation Limited ability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) > Note: Check the app-ooriate box in tne line above for the tax ciassification ofthe single-member owner. Do noi check | Exemption from FATCA reporting ‘disregarded from the ow'ior unless the ownor of the LLC is 5 fecera tax purposes. Otherwise, @ single-member LLC that Is disregarded from the owner snouid check the appropriate box for the tax classification of Its owner. certain enlties, nol individuals; see instructions on page 3) CO Parnershin C1 Truswestate Exempt peyee code {i any) code (i any) osha oases mariana ute Pe 15) 6 Address (number, street, and api. oF sulte no.) See instructions. Print or type. ‘See Specific Instructions on page 3. Requostor® seme and ederecs (oottona © Gily, state, and ZIP code 7 Uist account number(s) here (optional) WG2Ga__ Taxpayer identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded enxity, see the instruotions for Part |, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How 10 get a backup withholding. For individuals, this TIN, later. Note; If the account is in more than one name, see the instructions for line 1. Also sse What Name and ‘Nurnber To Give the Requester for guidelines on whose number to enter. [Secial security

ater. Note; If the account is in more than one name, see the instructions for line 1. Also sse What Name and ‘Nurnber To Give the Requester for guidelines on whose number to enter. [Secial security namiber Certification Under penalties of perjury, | certify that 4. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to be issued to me}; and 2.1.am not subject to backup withholding because: (a) | am exempt from backup withholding, or (0) | have not been notified by the Intemel Revenue Service (IRS) that | am subject to beckup withholding as a result of na longer subject to backup withholding; and 9.lamaU.S. citizen or other U.S. person (defined below); and jure to report all interest or dividends, or (c) the IRS has notified me that 4. The FATCA code(s) entered on this form (f any) indicating that | am exempt from FATCA reporting Is correct Certification instructions, You must cross out item 2 above F you have been notified by the IRS that you are currently subject to backup withholding because ‘you have failed to report al interest and cividends on your tax retum. For real estate transactions, item 2 does jon or abandonment of secured property, cancelation of debt, contributions to an individual retvement arrangement (/RA), and generally, payments not apply. For mortgage interest paid, acqh other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Par: ll, later. Sign | signature ot Here _| US. person Date > General Instructions ‘Section references are to the Internal Revenue Code unless otherwise noted. Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted alter they were published, go to www irs. gov/FornW9. Purpose of Form ‘An individual or entity (Form W-9 requesten who is required to file an information return with the IRS must obtain your correct taxpayer Identification number (TIN) which may be your soolel security number (SSN), individual taxpayer identification number (TIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), t0 report on an information ratumn the araunt paid to you, or other ‘amount reportable on an information retum. Examples of information returns

number (ATIN), or employer identification number (EIN), t0 report on an information ratumn the araunt paid to you, or other ‘amount reportable on an information retum. Examples of information returns include, but ere not limited to, the following. * Form 1098-INT (interest earned or paid) *# Form 1089-DIV (dividends, including those from stocks or mutual funds) + Form 1089-MISC (various types of income, prizes, awards, or gross proceeds) * Form 1089-8 (stock or mutual fund sales and certain other transactions by brokers) * Form 1099-S (proceeds from real estate transactions) + Form 1099-K (merchant card and third perty network transactions) + Form 1098 (home mortgage interest), 1088-£ (student loan interest), 1088-T (tuition) * Form 1089-C (canceled debt) * Form 1099-A (acquisition or abandonment of secured property) Use Form W-9 oniy if you are.@ U.S. perso (Including a resident alien), to provide your correct TIN. |f you do not retum Form W-9 to the requester with @ bbe subject to backup withholding. deter. TIN, you might . See What is backup withholding, ‘Cat. No, 10231K Forn W-9 (Rev. 10-2018) P-52

STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Business Registration Certification and Public Works Contractor Registration Certification Effective September 1, 2004, the State has expanded its Contractor Registration Program to local Government contracts, P.L. 2004, ¢57. All business organizations that do business with a local government agency are required to be registered with the State. The business must provide proof of that registration to the local government agency before that local government agency can enter into a contract with the business. A copy of the Business Registration Certificate must also be on file before any purchase order/voucher or other contracting document can be issued. Contractors are responsible for notifying subcontractors. Further information and registration can be obtained online from the NJ Treasury, Division of Revenue or by calling (609) 292-1730. aldoioiotoaie ii i toi fot ioiaioioioiok P.L. 1999 Chapter 238. The Public Works Contractor Registration Act specifies that no contractor or subcontractor shall bid on or engage in any contract (or part thereof) for public work which is subject to the provisions of the “New Jersey Prevailing Wage Act”, P.L. 1963 C. 150 (c. 34:11-56.25 et seq.) for the construction, reconstruction, demolition, alteration, repair, or maintenance of a public building regularly open to and used by the general public or public institution, and includes any subcontractor or lower tier subcontractor of a contractor unless they are registered with the Commissioner of Labor. P-53

SAMPLE CERTIFICATE eT ‘“ - STATE OF NEW JERSEY Sp BUSINESS REGISTRATION CERTIFICATE ff oerantuane usw | FOR STATE AGENCY AND CASINO SERVICE CONTRACTOR j 70.00% 282 a f TAXPAYER NAME TRALE VANE ; TAX REGISTRATION TEST ACCOUNT cul LLSTRAT i TAXPAYER IDENTIFICATIONS SEQUE NE NUMBER i 970-097-382/800 o107: H ANDPESS ISSUANCE DATE od cee doe o7/14io8 VE DA owe STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Tuapayer Name: VAX REG TEST ACCOUNT Trade Name: Address: 847 ROLBLING AVE TRENTON. NJ 08611 Certificate Number: 1093907 October 14. 2004 Date of Issuance: For Office Use Only: 20041014112823533 P-54

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