4-DisclosureofProhibitedActivitesinRussiaBelarus.pdf
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- Attached to
- Insurance Services
- Solicitation number
- BCUA-RFQ-26-006
- Issued by
- Bergen County, New Jersey
About this file
This is a Certification of Noninvolvement in Prohibited Activities in Russia or Belarus form required by New Jersey State law (N.J.S.A. 52:32-60.1, et seq.) for vendors seeking to enter into or renew contracts with State agencies for the provision of goods or services, or the purchase of bonds or other obligations. The certification applies to the Bergen County Utilities Authority's Request for Pre-Qualification (RFPQ) for Insurance Services, which seeks qualified firms to provide General Insurance Consultant, Insurance Broker, and Risk Manager services. Vendors must complete the certification by confirming their status against the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list and checking the appropriate box indicating whether they are identified on the list due to Russia and/or Belarus-related activities.
Vendors must certify one of three conditions: (A) that they are not identified on the OFAC list due to Russia and/or Belarus activity; (B) that they are unable to certify because they are identified on the OFAC list due to such activity; or (C) that while identified on the OFAC list, their Russia and/or Belarus activity is consistent with federal law, regulation, license, or exemption, with detailed explanations required. The certification requires submission of vendor contact information, Federal Employer Identification Number (FEIN), authorized representative signature, and date. Failure to provide accurate certification may result in sanctions, debarment, suspension, declaration of default, or recovery of damages by the Department of the Treasury. This certification is a prerequisite compliance document for all vendors bidding on this New Jersey contract opportunity.
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Text version
CERTIFICATION OF NON‐INVOLVEMENT IN
PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS
NJ Rev. 1.22.2024
Pursuant to N.J.S.A. 52:32-60.1, et seq. (L. 2022, c. 3) any person or entity (hereinafter “Vendori”) that seeks to enter into or renew a contract with a State agency for the provision of goods or services, or the purchase of bonds or other obligations, must complete the certification below indicating whether or not the Vendor is identified on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, available here:
https://sanctionssearch.ofac.treas.gov/. If the Department of the Treasury finds that a Vendor has made a certification in violation of the law, it shall take any action as may be appropriate and 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, the undersigned, certify that I have read the definition of “Vendor” below, and have reviewed the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, and having done so certify:
(Check the Appropriate Box)
A. That the Vendor is not identified on the OFAC Specially Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.
OR
B. That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated Nationals and Blocked Persons list on account of activity related to Russia and/or Belarus.
OR
C.
That I am unable to certify as to “A” above, because the Vendor is identified on the OFAC Specially Designated Nationals and Blocked Persons list. However, the Vendor is engaged in activity related to Russia and/or Belarus consistent with federal law, regulation, license or exemption. A detailed description of how the Vendor’s activity related to Russia and/or Belarus is consistent with federal law is set forth below.
(Attach Additional Sheets If Necessary.)
Signature of Vendor’s Authorized Representative Date
Print Name and Title of Vendor’s Authorized Representative Vendor’s FEIN
Vendor’s Name Vendor’s Phone Number
Vendor’s Address (Street Address) Vendor’s Fax Number
Vendor’s Address (City/State/Zip Code) Vendor’s Email Address i Vendor means: (1) A natural person, corporation, company, limited partnership, limited liability partnership, limited liability company, business association, sole proprietorship, joint venture, partnership, society, trust, or any other nongovernmental entity, organization, or group; (2) Any governmental entity or instrumentality of a government, including a multilateral development institution, as defined in Section 1701(c)(3) of the International Financial Institutions Act, 22 U.S.C. 262r(c)(3); or (3) Any parent, successor, subunit, direct or indirect subsidiary, or any entity under common ownership or control with, any entity described in paragraph (1) or (2).
https://pub.njleg.state.nj.us/Bills/2022/PL22/3_.PDF https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/ https://sanctionssearch.ofac.treas.gov/
| Vendors Phone Number: |
| Vendors Fax Number: |
| Vendors Email Address: |
| Group1: Off |
| the Vendors activity related to Russia andor Belarus is consistent with federal law is set forth below 1: |
| the Vendors activity related to Russia andor Belarus is consistent with federal law is set forth below 2: |
| the Vendors activity related to Russia andor Belarus is consistent with federal law is set forth below 3: |
| the Vendors activity related to Russia andor Belarus is consistent with federal law is set forth below 4: |
| the Vendor’s activity related to Russia and/or Belarus is consistent with federal law is set forth below 5: |
| the Vendor’s activity related to Russia and/or Belarus is consistent with federal law is set forth below 6: |
| Signature of Vendor's Authorized Representative: |
| Print Name and Title of Vendors Authorized Representative: |
| Vendors Name: |
| Vendors Address Street Address: |
| Vendors Address CityStateZip Code: |
| Date: |
| Vendors FEIN: |
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