Township Council Meeting — Packet

FEDERAL NON-DEBARMENT CERTIFICATION CERTIFICATION OF NON-DEBARMENT FOR FEDERAL GOVERNMENT CONTRACTS N.J.S.A. 52:32-44.1 (P.L. 2019, c.406) This certification shall be completed, certified to, and submitted to the contracting unit Prior to contract award, except for emergency contracts where submission is required prior to payment. PART I: VENDOR INFORMATION Individual or Organization Name Physical Address of Individual or Organization Unique Entity ID (if applicable) CAGE/NCAGE Code (if applicable) Check the box that represents the type of business organization: Oole Proprietorship (skip Parts Ill and lV) CINon-Profit Corporation (skip Parts III and IV) Ofor-Profit Corporation (any type) OLimited Liability Company (LLC) OPartnership OLimited Partnership Limited Liability Partnership (LLP) Other (be specific): PART II — CERTIFICATION OF NON-DEBARMENT: Individual or Organization | hereby certify that the individual or organization listed above in Part I is not 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 the 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 that it will constitute a material breach of my agreement(s) with the Township of West Orange permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Full Name Title: (Print): Signature: Date: P-49