DisclosureofProhibitedActivitesinRussiaBelarus_(2).pdf

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2025-102
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Essex County, New Jersey

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Certification of Noninvolvement in Prohibited Activities in Russia or Belarus

This document is a certification form required by the State of New Jersey pursuant to N.J.S.A. 52:32-60.1 (L. 2022, c. 3) for any vendor seeking to enter into or renew a contract with a state agency for the provision of goods or services or the purchase of bonds. Vendors must complete the certification to indicate whether they are identified on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list. The form provides three certification options: (A) certifying that the vendor is not identified on the OFAC list due to activity related to Russia and/or Belarus; (B) certifying inability to confirm option A because the vendor is identified on the OFAC list for Russia and/or Belarus-related activity; or (C) certifying inability to confirm option A but affirming that any Russia and/or Belarus-related activity is consistent with federal law, regulation, license, or exemption. Vendors must provide detailed vendor information including business name, FEIN, contact details, and the signature of an authorized representative with the date of certification.

The certification requirement applies to all vendors, broadly defined to include natural persons, corporations, partnerships, limited liability entities, business associations, governmental entities, and any parent, successor, subsidiary, or entity under common ownership or control with the foregoing. The Department of Treasury retains authority to impose sanctions, seek compliance, recover damages, declare parties in default, or pursue debarment or suspension against any vendor found to have made a false certification. Vendors are required to review the OFAC Specially Designated Nationals and Blocked Persons list available at https://sanctionssearch.ofac.treas.gov/ prior to completing the certification.

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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. (L. 2022, c. 3) any person or entity (hereinafter “Vendori”) that seeks to enter into or renew a contract with a State agency 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://pub.njleg.state.nj.us/Bills/2022/PL22/3_.PDF 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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