Disclosure_of_Iran_Investments_(New).pdf
PDF 393 KB Posted
- Attached to
- Sign Post, Traffic State and local contract opportunity
- Solicitation number
- 2025-33
- Issued by
- Essex County, New Jersey
About this file
This document is a Disclosure of Investment Activities in Iran form from the New Jersey Department of the Treasury, which is part of a bidding process for a Sign Post, Traffic contract with the City of Newark. The form requires bidders to certify whether they or their parent/subsidiary entities have any investment activities in Iran, in compliance with Public Law 2012, c. 25. Bidders must carefully review the Chapter 25 List on the Treasury's website and attest to their status by either checking a box confirming no Iranian investments or providing detailed information about any such activities.
The document outlines potential consequences for non-compliance, including sanctions, damages, default declarations, and potential debarment or suspension. Bidders are required to provide a sworn certification of the accuracy of their disclosure and acknowledge that making false statements is a criminal offense. The form includes three parts: a certification section where bidders declare their Iranian investment status, an additional information section for those with Iranian investments, and a final certification of true and complete information with signature and date fields.
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| Sign_Post,_Traffic.pdf | ||
| W-9_(March2024).pdf | ||
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Text version
Disclosure of Investment Activities in Iran
Person or Entity
Part 1: Certification
COMPLETE PART 1 BY CHECKING EITHER BOX.
Pursuant to Public Law 2012, c. 25, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or renew a contract, must complete the certification below to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate is identified on the
State Department of Treasury's Chapter 25 list as a person or entity engaging in investment activities in Iran.
The list is found on Treasury’s website at www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.
The Chapter 25 list must be reviewed prior to completing the below certification. If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may 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 certify, pursuant to Public Law 2012, c. 25, that neither the person or entity listed above, nor any parent entity, subsidiary, or affiliate thereof is listed on the N.J.
Department of the Treasury’s list of entities determined to be engaged in prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). I further certify that I am the person listed above, or I am an officer or representative of the entity listed above and am authorized to make this certification on its behalf. I will skip
Part 2 and sign and complete the Certification below.
OR
I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or affiliate thereof is listed on the N.J. Department of the Treasury’s
Chapter 25 list. I will provide a detailed, accurate and precise description of the activities in Part 2 below sign and complete the Certification below.
http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf
Part 2: Additional Information
PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN.
You must provide a detailed, accurate and precise description of the activities of the person or entity, or a parent entity, subsidiary, or affiliate thereof engaging in investment activates in Iran below and, if more space is needed, on additional sheets provided by you.
Part 3: Certification of True and Complete Information
I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments there to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on behalf of the above-referenced person or entity.
I acknowledge that the Name of Contracting Unit is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the Reference to Contracting Unit to notify the Reference to Contracting Unit in writing of any changes to the answers of information contained herein.
I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the Name of
Contracting Unit and that the Reference to Contracting Unit at its option may declare any contract(s) resulting from this certification void and unenforceable.
Full Name (Print)
Title
Signature Date
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