6- BLANK Iran Disclosure Form.pdf
PDF 130 KB Posted
- Attached to
- Laboratory Testing - UG/AG Storage Tanks - COOP
- Solicitation number
- BC-BID-26-06
- Issued by
- Bergen County, New Jersey
About this file
This 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, for use in connection with the Laboratory Testing - UG/AG Storage Tanks - COOP bid solicitation (BC-BID-26-06). The form is a mandatory certification document that bidders and vendors must complete and submit as part of their bid or proposal to enter into or renew a contract with the State of New Jersey. Bidders are required to certify their compliance with N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4) by confirming that neither they nor any of their parents, subsidiaries, or affiliates appear on the New Jersey Department of the Treasury's Chapter 25 List of entities engaged in prohibited investment activities in Iran.
The form provides two certification options: vendors may certify full compliance with the Iran investment restrictions, or they must disclose any listed entities and provide detailed descriptions of their prohibited activities, including the relationship to the vendor, nature of activities, duration of engagement, and anticipated cessation date. Vendors must review the Chapter 25 List prior to completing the certification and acknowledge that false statements constitute criminal offenses and material breaches of contract. The State of New Jersey reserves the right to impose sanctions, seek compliance, recover damages, declare parties in default, or seek debarment or suspension for violations. Vendors remain under a continuing obligation to notify the State in writing of any changes to disclosed information throughout the contract period.
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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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