7-1-2024 Blank - LPCL Disclosure of Prohibited Activities in Russia-Belarus.pdf
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- 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 Certification of Noninvolvement in Prohibited Activities in Russia or Belarus form issued by the State of New Jersey for vendors seeking to enter into or renew contracts with local contracting units under the Local Public Contracts Law. The form, updated January 22, 2024, requires vendors to certify their status relative to the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list. Vendors must indicate whether they are not identified on the OFAC list due to Russia or Belarus-related activity, unable to certify due to such identification, or unable to certify but engaged in Russia or Belarus activity consistent with federal law, regulation, license, or exemption. The certification applies to any entity seeking to provide goods or services, purchase bonds, or enter into other contractual relationships with New Jersey local contracting units.
The form defines "Vendor" broadly to include natural persons, corporations, partnerships, limited liability entities, sole proprietorships, joint ventures, trusts, governmental entities, and any parent, successor, subsidiary, or entity under common ownership or control with such entities. Vendors must provide detailed contact information, Federal Employer Identification Number (FEIN), and authorized representative signature and date. If a vendor cannot certify non-involvement, it must provide a detailed written explanation of how its Russia or Belarus-related activities comply with applicable federal law. The Department of the Treasury reserves the right to impose sanctions, seek compliance, recover damages, declare parties in default, or seek debarment or suspension of any vendor making false certifications.
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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. and N.J.S.A.40A:11-2.2 (L. 2022, c. 3) any person or entity (hereinafter “Vendor”) that seeks to enter into or renew a contract with a local contracting unit subject to the Local Public Contracts Law 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://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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