7-2024 Blank - LPCL Disclosure of Prohibited Activities in Russia-Belarus.pdf
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- 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 Certification of Noninvolvement in Prohibited Activities in Russia or Belarus form issued by New Jersey pursuant to N.J.S.A. 52:32-60.1 et seq. and N.J.S.A. 40A:11-2.2 for vendors seeking to enter into or renew contracts with local contracting units under the Local Public Contracts Law. The certification applies to vendors providing goods, services, or purchasing bonds or other obligations. Any vendor must complete this form by reviewing the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list and certifying their compliance status regarding activity related to Russia and/or Belarus. The form requires vendors to select one of three certification options: confirming they are not identified on the OFAC list due to Russia or Belarus-related activity, indicating they cannot provide such certification due to OFAC listing, or confirming OFAC listing exists but their Russia or Belarus-related activity complies with federal law, regulation, license, or exemption.
The certification form requires vendors to provide complete company information including legal name, Federal Employer Identification Number (FEIN), address, phone number, fax number, and email address. An authorized representative must sign and date the certification, with printed name and title required. If a vendor selects the third certification option, they must provide a detailed written description of how their Russia or Belarus-related activity is consistent with federal law, with provisions for additional documentation as necessary. The Department of the Treasury is authorized to impose sanctions, seek compliance, recover damages, declare parties in default, or seek debarment or suspension for any vendor making false certifications in violation of state law.
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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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