Township Council Meeting — Packet

Section C — Part Ill Certification | hereby certify that no individual or organization that is debarred by the federal government from contracting with a federal agency owns greater than 50 percent of the Organization listed above in Part | or, if applicable, owns greater than 50 percent of a parent entity of . | further acknowledge: that | am authorized to execute this certification on behalf of the abovenamed 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 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, lam 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: Part IV — CERTIFICATION OF NON-DEBARMENT: Contractor — Controlled Entities Section A Below is the name and address of the corporation(s) in which the Organization listed in Part | owns more than 50 percent of voting stock, or of the partnership(s) in which the Organization listed in Part | owns more than im 50 percent interest therein, or of the limited liability company or companies in which the Organization listed above in Part | owns more than 50 percent interest therein, as the case may be. Name of Business Entity Physical Address **Add additional sheets if necessary** OR The Organization listed above in Part | does not own greater than 50 percent oO of the voting stock in any corporation and does not own greater than 50 percent interest in any partnership or any limited liability company. P-51