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 in oO Part Ill A owns greater than 50 percent of the voting stock (corporation) or owns greater than SO 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 No entity listed in Part Ill A owns greater than 50 percent of the voting stock oO in any corporation or owns greater than 50 percent interest in any partnership or limited liability company. Section C — Part IV Certification | 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): Title: Signature: Date: P-52

DUNS / FEDERAL ID NUMBER The undersigned Bidder hereby affirms the following to be their DUNS / Federal ID number as issued by the United States Federal Government. DUNS No. Federal ID No. Dated: (Bidder's Firm Name) (Authorized Signature) (Name and Title) P-53

INITIAL PROJECT WORKFORCE REPORT - CONSTRUCTION Official Use Only STATE OF NEW JERSEY Assignment DIVISION OF CONTRACT COMPLIANCE EQUAL EMPLOYMENT OPPORTUNITY IN PUBLIC CONTRACTS Code FORM 16-261 Reed 1803 INITIAL PROJECT WORKFORCE REPORT CONSTRUCTION Ee READ IN TONS ON PLEASE TYPE OR PRINT IN FID NUMBER BLACK OR BLUE INK. 2 CONTRACTOR 0 NUMEER ‘3. NAME AND ADORESS OF PUBLIC AGENCY AWARDING CONTRACT 3. NAME AND ADDRESS OF PRIME CONTRACTOR Came) CONTRACT NUMBER DATE OF AWARD DOLLAR AMOUNT OF AWARD Gieiadareny © NAME AND ADDRESS OF PROJECT PROTECT NUMBER (cigs) Gan) (Zip Code) county 8. 1S THIS PROJECT COVERED BY A PROJE( 4. 1S THIS COMPANY MINORITY OWNED [_] OR WOMAN OWNED [ ) LABOR AGREEMENT (PLA}? OYES ONC —— — — TRADE OR CRAFT PROJECTED PROJECTED PHASE -IN COMPLETION DATE DATE cone PROJECTED TOTAL EMPLOYEES PROJECTED MINORITY EMPLOYEES aa 1. ASBESTOS WORKER | 4. ELECTRICIAN 5. GLAZIER 6, HVAC MECHANIC 7. IRONWORKER 8. OPERATING ENGINEER 9, PAINTER 10. PLUMBER 11, ROOFER 12. SHEET METAL WORKER | 13. SPRINKLER FITTER 14. STEAMFITTER 15. SURVEYOR 16. TILER i= 17. TRUCK DRIVER 18. LABORER 19. OTHER 20, OTHER 4 —— Thereby certify that the foregoing statements made by ine are (rue. Lain aware (iat if any of tre for false, Lam subject to punishment. (Signature) To (Pleace Print Your Name) Tide (Area Code) (Telephone Number) Ext.) Dare) P-54

INSTRUCTIONS FOR COMPLETING THE INITIAL PROJECT WORKFORCE REPORT - CONSTRUCTION (AA201) DO NOT COMPLETE THIS FORM FOR GOODS AND/OR SERVICE CONTRACTS 1, 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 partnership. ws 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. 3. Enter the prime contractor's name, address and zip code number. 4. Check box 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. 6. Enter the name and address of the project, including the county in which the project is located. 7. Note: A project contract ID number will be assigned to your 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. 8. Check “Yes” or “No” to indicate whether a Project Labor Agreement (PLA) was established with the labor organization(s) for this project. 9. 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 co the Public Agency that awards the contract and the Division

ent Opportunity (EEO) official include signature and title, phone number and date the report is submitted. This report must be submitted co 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 08625-0209

FORM W-9 Request for Taxpayer am W-9 es teas Give Form to the ipiev, Ockcber nN Identification Number and Certification requester. Do not Departmen otha Trosu send to the IRS. internal Revenue Sari” > Go to www.irs.gov/FormW9 for instructions and the latest information, ame fas srown on your Teams tax tur, Name ls required on this fe donot leave tis ne Ulan 2 Business named aqardes eny nave, W arent on above | 3 Check appropriate a0x for federa tax ciassitcation of the person whose nae is eniered on ine 1 Check only one of the | 4 Exemotions (codes apply only to folowing soven boxes corn ets, rot individual; 968 instructions on page 3} O inenicuaeoe rosotoro OD ccorportion CO scopoaon O) Parversno C1) trsvestate ‘Single-membar' 171 Lmited ability company. Enter the tax classification (C=C corporation, $= corporation, P=Partnership) > Note: Check the appropriate box in tre line above for 278 tax c.assiicat 0 of the 1g @-member owner. DO not check LUG if the LLG is clasied as a singlo-nerber LLG thal is disragardad frorn the owrior urloss tha owner of the LLC Exempt payee code ff any) Exemplion rom FATCA reporting ‘nother LLC that Is nat disrogarcoed from na owner for U.S. federal tax; {s alsreqarcec from the owner snouid check the acpropriate box ter tne tax: 1 orter (soe inatructions) > Print or type. Otherwise, a single: member L1C that) 9 ary) classiication ot Its owner. ete acct mentee fh 8) %6 Address (number, street, and apt or sue no.) Seo instructions Rlequester’s neme and adress (optional) ‘See Specific Instructions on se © Gy, sata, and ZIP cod 7 List account nomborta here (optional) ixpayer Identification Number (TIN) Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid ‘social security number (SSN). (+ disregarded enity, $e the instructions for Part I later. For eniiias, itis your employer identification number (EIN). If you do no: have a number, see How fo got a backup withholding, For individuals, this is generally your resident alien, sole TIN, later. Note: if the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. However, for a ‘other Certification Under penalties of perjury, | cerilfy that: 1. The number shown on this form is my correct taxpayer

Give the Requester for guidelines on whose number to enter. However, for a ‘other Certification Under penalties of perjury, | cerilfy that: 1. The number shown on this form is my correct taxpayer identification number (or | am waiting for a number to ba issued to me); and 2..1.am not subject to backup withholding because: (a) | am exempt from backup withholding, or (o) | have not been notified by the Internal Revenue Service (IRS) that | am suibject to no longer subject to backup withnokding; and 3. 1am a U.S. citizen or other U.S. person (detined below); and 4. The FATCA code(s) entored on this form (i any) indicating that | am exemat ‘backup withholding as a result of a falure to report all interast or dividends, or (c} the IRS has notified me that | am from FATCA reporting is correct. Certification instructions. You must cross out ite 2 above If you have been notified by the IRS that you are currently subject to sackup withholding because: ‘YoU have filec to report all interest and cividends on your tax return. For real estate transactions, iter 2 does not appy. For morgage interest paid, acquisition or abandonment of secured . cancellation of debt, contrioutions to an inivicual retirement arrar ingement (IRA), and generally, payments, property, other than interest and dividends, you are not required to sign the ceriication, bu: you must provide your correct TIN. See the instructions for Par: Il ller. Signature of 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 ‘elated to Form W-9 and its instructions, such as legislation enacted after they were published, go to werw irs. gov/FormW9. Purpose of Form ‘An individual or entity (Form W-9 requesier) who is required to file an Information return with the IRS must obtain your correct taxpayer dentlfication number (TIN) which may be your soolal security number (SSN), individual taxpayer dentification number (TIN), adoption taxpayer identification number (ATIN}, or employer identification number (EIN), to report on an information return the amaunt paid to you, or other amount reportable on an information retum. Examples of information returns Include, but are not limited to, the following. ** Form 1099-INT (interest eamed or paid) * Form 1099-DIV

to you, or other amount reportable on an information retum. Examples of information returns Include, but are not limited to, the following. ** Form 1099-INT (interest eamed or paid) * Form 1099-DIV (dividends, including those from stocks or mutual funds) * Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) * Form 1089-6 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 party network transactions) * Form 1098 (home mortgage interest), 1098-E (student loan interest), 1088-T (tuition) * Form 1099-C (canceled debt) * Form 1099-A (acquisition or abandonment of secured property) Use Form W-8 only if you are @ U.S. person (Inciuding a resident alien), to provide your correct TIN. it you do nat retum Form W-9 to the requester with a TIN, you might ‘be subject to backup withholding. See Wnat is backup withholding, later. ‘Cat. No, 10231 P-56 Fo W-9 (Rev. 10-2018)

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. SOIC SG Ria ok ick ack kf kta 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 (¢. 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-57

SAMPLE CERTIFICATE ric 2 AIM SY ied nnC lad peer STATE OF NEW JERSEY ker “ q j BUSINESS REGISTRAT ON CERTIFICATE | FOR STATE AGENCY ANO CASINO SERVICE CONTRACTOR TAXPAYER NAME AVE TAX REGISTRATION TEST ACCOUNT LA STRAI TAXPAYER IDENTIFICATIONS SEQL & NUMBER 970-087-362/800 0107: ARMMESS ISSUANCE DATE FLING A TRE ON NJ 086 ores anos VE DA owu i. «cor Tose Cervhcate 4 NOT suo grabie w war ara Pia ach eel orem STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE Tuapayer Name: TAX REG TEST ACCOUNT Trade Name: Address: 847 ROEBLING AVE TRENTON. NI 0861T Certificate Number: 1093907 Date of Issuance: Ovtaber 14. 2005 For Office Use Only: 200-41014112823533 P-58