6-1-BLANK Iran Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Right to Know Compliance and Surveying Services State and local contract opportunity
- Solicitation number
- BC-RFP-25-019
- Issued by
- Bergen County, New Jersey
About this file
This document is a Disclosure of Investment Activities in Iran Form issued by the State of New Jersey Department of the Treasury - Division of Purchase and Property, located at 33 West State Street in Trenton. The form requires vendors or bidders proposing to enter into or renew a contract to certify that they are not engaged in investment activities in Iran, as mandated by New Jersey State statutes N.J.S.A. 52:32-57 and subsequent legislative acts.
The form requires vendors to review the New Jersey Department of the Treasury's Chapter 25 List and affirm that neither the vendor nor its parent companies, subsidiaries, or affiliates are listed as conducting prohibited investment activities in Iran. Vendors must check one of two boxes: either certifying they are not on the Chapter 25 List, or acknowledging their presence on the list and providing detailed information about their Iranian investment activities. The document emphasizes potential consequences for non-compliance, including sanctions, default declarations, and possible debarment. Vendors must sign and date the certification, acknowledging that providing false information could result in criminal prosecution and contract voiding.
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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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