6-1-BLANK Iran Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Environmental: Sampling and Consulting Services
- Solicitation number
- BC-RFP-26-004
- Issued by
- Bergen County, New Jersey
About this file
This is a Disclosure of Investment Activities in Iran Form required by the State of New Jersey Department of the Treasury, Division of Purchase and Property, for the Environmental: Sampling and Consulting Services contract opportunity (BC-RFP-26-004). The form mandates that all vendors and bidders certify their compliance with N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4) prior to submitting bids or proposals. Vendors must confirm that neither they nor any of their parents, subsidiaries, or affiliates are identified on the New Jersey Department of the Treasury's Chapter 25 List as entities engaged in investment activities in Iran. The form requires vendors to review the Chapter 25 List, available on the Division's website, before completing the certification.
The form provides two certification options for vendors: either certification that neither the vendor nor any related entities are listed on the Chapter 25 List, or disclosure and detailed description of any investment activities in Iran if the vendor or related entities are listed. Vendors selecting the second option must provide specific information regarding the entity engaged in investment activities, its relationship to the vendor, a description of activities, duration of engagement, and anticipated cessation date. The certification must be executed by an authorized representative under penalty of perjury, with acknowledgment that false statements constitute criminal offense and material breach of contract, potentially resulting in contract voidance and debarment or suspension of the vendor.
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Text version
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN FORM
STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY - DIVISION OF PURCHASE AND PROPERTY
33 WEST STATE STREET, P.O. BOX 230 TRENTON, NEW JERSEY 08625-0230
DPP Rev. 12.13.2021
BID SOLICITATION # AND TITLE:
VENDOR NAME:
Pursuant to N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4) any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must certify that neither the person nor entity, nor any of its parents, subsidiaries, or affiliates, is identified on the New Jersey Department of the Treasury’s Chapter 25 List as a person or entity engaged in investment activities in Iran. The Chapter 25 list is found on the Division’s website at https://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. Vendors/Bidders must review this list prior to completing the below certification. If the Director of the Division of Purchase and Property finds a person or entity to be in violation of the law, s/he shall take 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.
CHECK THE APPROPRIATE BOX
I certify, pursuant to N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4), that neither the Vendor/Bidder listed above nor any of its parents, subsidiaries, or affiliates is listed on the New Jersey Department of the Treasury’s Chapter 25 List of entities determined to be engaged in prohibited activities in Iran.
OR
I am unable to certify as above because the Vendor/Bidder and/or one or more of its parents, subsidiaries, or affiliates is listed on the New Jersey Department of the Treasury’s Chapter 25 List. I will provide a detailed, accurate and precise description of the activities of the Vendor/Bidder, or one of its parents, subsidiaries or affiliates, has engaged in regarding investment activities in Iran by completing the information requested below.
Entity Engaged in Investment Activities Relationship to Vendor/ Bidder Description of Activities
Duration of Engagement Anticipated Cessation Date *Attach Additional Sheets If Necessary.
CERTIFICATION
I, the undersigned, certify that I am authorized to execute this certification on behalf of the Vendor, that the foregoing information and any attachments hereto, to the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying on the information contained herein, and that the Vendor is under a continuing obligation from the date of this certification through the completion of any contract(s) with the State to notify the State in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do so, I may be subject to criminal prosecution under the law, and it will constitute a material breach of my contract(s) with the State, permitting the State to declare any contract(s) resulting from this certification void and unenforceable.
Signature Date
Print Name and Title https://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf
| BID SOLICITATION # & TITLE: |
| Name of Vendor / Bidder / Contractor: |
| Entity Engaged in Investment Activities: |
| Relationship to Vendor/ Bidder: |
| Description of Activities 1: |
| Description of Activities 2: |
| Description of Activities3: |
| Duration of Engagement: |
| Anticipated Cessation Date: |
| Signature 2: |
| Print Name and Title of Authorized Representative 2: |
| Date Signed_af_date: |
| Group1: Off |
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