Township Council Meeting — Packet

HOLD HARMLESS AGREEMENT BETWEEN THE TOWNSHIP OF WEST ORANGE AND Company Name Address (Not Post Office Box) Telephone Number Organization Type (Individual, Partnership, Non-Profit Corporation, Corporation, Public Entity) The bidder awarded the contract under the bid specifications shall indemnify and hold harmless the Township of West Orange, its officers, employees, agents and servants from and against any and all claims, demands, suits, actions, recoveries, judgments, costs and expenses including attorney's fees incurred or suffered on account of property damage or loss and/or personal injury, including loss of life, of any person, agency, corporation or governmental entity which shall arise out of the course of or in consequence to any acts or omissions of the bidder, its employees, agents, servants or subcontractors in the performance of the work to be reimbursed pursuant to these specifications or the failure of the bidder, its employees, agents, servants or subcontractors to comply with any term or condition of these specifications. The bidder further agrees that this indemnification by the bidder shall continue after completion of the contract for all claims, demands, suits, actions, recoveries, judgments, costs and expenses, including attorney's fees resulting from acts or omissions of the bidder, its employees, agents, servants or subcontractors which occur prior to the completion of the contract. Signed this _______ day of _______ 20___ as The binding act in deed of __________________ Business Name Authorized Signature Type or Print Name Witness P-44

SUBCONTRACTOR LIST The Contractor shall list below all Subcontractors that will be working on this Project. Business Registration, New Jersey Public Works Contractor Certification and proof of insurance must be submitted prior to award of Contract. A Valid Business Registration issued by the State of New Jersey is to be provided prior to the Award of Contract. The Business Registration Certificate must be obtained by the Subcontractor prior to the receipt of Bids, however, a Business Registration Certificate is not required in the submission of the Proposal forms for this Contract. Name of Subcontractor Address/Telephone # Work to be performed ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ DATE: P-45

DISCLOSURE OF POLITICAL CONTRIBUTIONS C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Contractor Instructions Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to a “fair and open” process (defined at N.J.S.A. 19:44A-20.7) are subject to the provisions of N.J.S.A. 19:44A-20.26. This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contributions to: • any continuing political committee (a.k.a., political action committee) • any candidate committee of a candidate for, or holder of, an elective office: o of the public entity awarding the contract o of that county in which that public entity is located o of another public entity within that county o or of a legislative district in which that public entity is located or, when the public entity is a county, of any legislative district which includes all or part of the county The disclosure must list reportable contributions to any of the committees that exceed $200 per election cycle that were made during the 12 months prior to award of the contract. See N.J.S.A. 19:44A-8 and 19:44A-16 for more details on reportable contributions. N.J.S.A. 19:44A-20.26 itemizes the parties from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: • individuals with an “interest” ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit • all principals, partners, officers, or directors of the business entity or their spouses • any subsidiaries directly or indirectly controlled by the business entity • IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business entity and filing as continuing political committees, (PACs). When the business entity is a natural person, “a contribution by that person’s spouse or child, residing therewith, shall be deemed to be a contribution by the business entity.” [N.J.S.A. 19:44A-20.26(b)] The contributor must be

a natural person, “a contribution by that person’s spouse or child, residing therewith, shall be deemed to be a contribution by the business entity.” [N.J.S.A. 19:44A-20.26(b)] The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall 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. P-46

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 no later than 10 days prior to the award of the contract. Part I – Vendor Information Vendor Name: Address: City: State: 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 II – 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.  Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount $  Check here if the information is continued on subsequent page(s) P-47

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-Maplewood Verona Borough West Essex Regional West Orange Town Fire Districts (Board of Fire Commissioners): NONE P-48

DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN STANDARD BID DOCUMENT REFERENCE Name of Form DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN N.J.S.A. 52:32-55 et seq. Statutory N.J.S.A. 40A:11-2.1 Reference N.J.S.A. 18A:18A-49.4 Y/N Mandatory Optional N/A Goods and Applicability LPCL Y X Services PSCL Y Construction X Instructions Reference P.L. 2012, c.25 prohibits the awarding of State and local public contracts for goods and Description services with persons or entities engaging in certain investment activities in energy or finance sectors of Iran. Prior to contract award, vendors and contractors must certify that neither they nor any parent entity, subsidiary, or affiliate is listed on the New Jersey Department of the Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). The Certification form requires the insertion of contracting unit identification information which should be filled in (in italics on the form) prior to its use. P-42

Disclosure of Investment Activities in Iran Person or Entity Part 1: Certification COMPLETE PART 1 BY CHECKING EITHER BOX. Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate is identified on the State Department of Treasury's Chapter 25 list as a person or entity engaging in investment activities in Iran. The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. The Chapter 25 list must be reviewed prior to completing the below certification. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may 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. I certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s list of entities determined to be engaged in prohibited  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 representative of the entity listed above and am authorized to make this certification on its behalf. I will skip Part 2 and sign and complete the Certification below. OR I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s Chapter 25 list. I will provide a detailed, accurate and precise description of the  activities in Part 2 below sign and complete the Certification below.

. I will provide a detailed, accurate and precise description of the  activities in Part 2 below sign and complete the Certification below. P-43

Part 2: Additional Information PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN. You must provide a detailed, accurate and precise description of the activities of the person or entity, or a parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below and, if more space is needed, on additional sheets provided by you. Part 3: Certification of True and Complete Information I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments there to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above-referenced person or entity. I acknowledge that the TOWNSHIP OF WEST ORANGE is relying on the information contained herein and thereby acknowledge 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 in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and 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 at its option may declare any contract(s) resulting from this certification void and unenforceable. Full Name Title (Print) Signature Date P-44