Township Council Meeting — Packet

f ' 1 | STATEMENT OF OWNERSHIP DISCLOSURE NLLS.A, 52:25-24.2 (P.L. 1977, 0.33, as amended by P.L. 2016, ¢.43) This statement shall be completed, certified to, aud included with all bid and proposal submissions, Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Organization Address: Part I Check the box that represents the type of business organization: Oo Sole Proprietorship (skip Parts II and UJ, execute certification in Part IV) Cd non-profit Corporation (skip Parts I and II, execute certification in Part IV) O For-Profit Corporation (any type) Phiimites Liability Company (LLC) | Partnership | Limited Partnership Limited Liability Partnership (LLP) Dotter (be specific): Part Oo The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR | No one stockholder in the corporation owns 10 percent or mote of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR LLC MEMBERS LISTED IN PART IT Ifa bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annua! filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person, Attach additional sheets if more space is needed, Website (URL) containing the last annua! SEC (or foreign equivalent) filing Page #’s Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part SI other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every non-corporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.LS.A, 52:25-24.2 has been listed. Attach additional sheets if more space is needed. Stockholder/Partner/Member and Address Corresponding Entity Listed in Part II Part IV Certification I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. | acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer, that the Township of West Orange is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with Township of West Orange to notify the Township of West Orange in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a faise statement or misrepresentation in this certification, and if I do so, I] am subject to criminal prosecution under the law and

ined herein; that I am aware that it is a criminal offense to make a faise statement or misrepresentation in this certification, and if I do so, I] am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township of West Orange to declare any contract(s) resulting from this certification void and unenforceable. Page | 29

Title: Date: Full Name (Print): Signature: Page | 30

CERTIFICATION OF NON-INVOLVEMENT IN PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS Pursuant to NJ.S,A, 62:32-60.1, et seq (L, 2022, c, 3) arly person or eiity {hereitiafler "Vendor") thal seeks to shite into or ranev-a contract with a State agenay forthe provision of goods or services, or the purchase of bonds or othst obligations, must complete the certification below indicating whether or ict. the Vendor ‘s ‘identified on the Office of Foreign Assets tro) FAC) Specially Designated Nationals and Blocked Persons. isl, vallable Here: e [the Department of the Treasury finds that a Vendor has made. a certification in ‘Woletion of tha law, it shall take ‘any action'as may be appropriate and provided by law, rulé or contract, including but not lifted to, linposing sanétions, Seeking compliance, recovering damages, declaring the party if default aid seeking dabarmant orsuspeasion of the party. |, fie undersigned, ceitify Hist | have reed the definition of “Varitor" bélow, and have raviewed the Offica of Foreign Assets Cortrol (OFAG): Specially Designated Nationals and Blocked Persons list, and having dangesa certify: (Ghetk the Appropriate Box) 4, thatthe Vendor is not ideniified on the FAG. Spa oO gosddunt of adlivity related to Russta and/or Belarus, OR p, ‘That lam unable to certify as-to “AY above, bocause the Vendor is identified on the OFAC Spésially OQ * Desianated Nationals shd Blocked Persons list onl acount of nctivity related to Russia andor Belarus, ‘OR ‘That |-em uneble to certify as to “A shove, becausé the Vendor is Idefttified on ihe ofa Sbecially ) <. ‘Desiqnated Nationals:and Blocked Persons list. Hewever, the: Vendor is engaged Inactivily related to Russia " and/or Belanis nonsistent with federal law, regulation, license er-exemption. A detailed description of how the Vendor's activity related fo Russia and/or Belarus is: consistent with federal jaw is set forth below. (Aitanti Adtilianal Shoots if Necossay) ‘Signature oF Vendor's Authorized Representative Bate PriitNarne and Tike of Veridrs Authorized Reprocuntabve, Vendors FEIN ‘Vendor's Name Vendors Prone Number Vendors Address (Sirset Address} Vendor's Bax Number Vendor's Address (GiiiStatelZip Gade) ‘Vendors Emall Address | Wendor means: (1) A-netural person, corporation, company, lined partnership, limited ilablily partnership, limited Nablity company; bushesy-nssoclation, sole

iStatelZip Gade) ‘Vendors Emall Address | Wendor means: (1) A-netural person, corporation, company, lined partnership, limited ilablily partnership, limited Nablity company; bushesy-nssoclation, sole proprictorship, foint ventore, partnership, soclety, trust, or any ther nongovernmental ently, organizalion, or gous (@j Any governmental entity-or insttumertality of a goverment, frelaling a thullilateral develonment Institution, 8s defined in Section 470140\(3) of the international Financial Institutions Act, 22 U.8.G, 262/(0)(3)° or (8) Any ‘parent, stiocessot, susunit, direct or indirect Subsidiry,-ot-any sntily under commdn ownership or control with, any enfity described in paragraph (4) or (2). Noy, {h004 Page | 31

TOWNSHIP OF WEST ORANGE ACKNOWLEDGMENT OF RECEIPT OF ADDENDA The undersigned Bidder hereby acknowledges receipt of the following addenda: Please assign the number, date and initial. Addendum Number Dated Acknowledge Receipt (Initial) [1 No addenda was/were received. Acknowledged for: (Company Name) By: | (Signature of Authorized Representative) ! | Name: (Print) | Title: | Date: Page | 32

AMERICANS WITH DISABILITIES ACT OF 1990 Equal Opportunity for Individuals with Disability The contractor end the Township of West Orange, (hereafter “TOWNSELP") do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "Act") (42 U.S.C. $121 01 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, activities provided or made available by public entities, and the rules and regulations promulgated pursuant there unto, are made a part of this contract. In providing any aid, benefit, or service on behalf of the TOWNSHIP pursuant to this contract, the contractor agrees that the performance shall be in strict compliance with the Act. In the event that the contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the contractor shall defend the TOWNSHIP in any action or administrative proceeding commenced pursuant to this Act. ‘The contractor shall indemnify, protect, and save harmless the TOWNSHIP, its agents, servants, and employees from and against any and all suils, claims, losses, demands, or damages, of whatever kind of nature arising out of or claimed to arise out of the alleged violation. The contractor shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and ail complaints brought pursuant to the TOWNSHIP's grievaace procedure, the contractor agrees to abide by any decision of the TOWNSHIP which is rendered pursuant to said grievence procedure. If any action or administrative proceeding results in an award of damages against the TOWNSHIP, or if the TOWNSHIP incurs any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the contractor shall satisfy and discharge the same at its own expense. ‘The TOWNSHIP shall, as soon as practicable after a claim has been made against it, give written notice thereof to the contractor along with full and complete particulars of the claim, if any action or administrative proceeding is brought against the TOWNSHIP or any of its agents, servants, and employees, the TOWNSHIP shall expeditiously forward or

complete particulars of the claim, if any action or administrative proceeding is brought against the TOWNSHIP or any of its agents, servants, and employees, the TOWNSHIP shall expeditiously forward or have forwarded to the contractor every demand, complaint, notice, summons, pleading, or other process received by the TOWNSHIP or its representatives. Tt is expressly agreed and understood that any approval by the TOWNSHIP of the services provided by the contractor pursuant to this contract will not relieve the contractor of the obligation to comply with the Act and to defend, indemnity, protect, and save harmless the TOWNSHIP pursuant to this paragraph. Ivis further agreed and understood that the TOWNSHIP assumes no obligation to indemnify or save harmless the contractor, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the contractor expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the contractor's obligations assumed in this Agreement, nor shall they be construed to relieve the contractor from aay liability, nor prechide the TOWNSHIP from taking any otler actions available to it under any other provisions of the Agreement or otherwise at law. Tacknowledge: Signature of Vendor Page | 33 i i i 4

BIDDER’S CHECK LIST Business Registration Certification { Statement of Ownership | Affirmative Action Compliance Notice Prohibited Iran Investment Activities Prohibited Russia-Belarus Activities i Non-Collusion Affidavit Proposal Form —_—___ Acknowledgement of Addenda Political Contribution Form Bidders must provide documented proof of qualifications (Certifications) Three (3) references; Company, Name, Address, and Phone number Americans with Disabilities Act of 1990 Please initial lines Please provide one additional copy of entire bid package, which SHOULD be a USB/Flash Stick END OF BID Page | 34