DisclosureofProhibitedActivitesinRussiaBelarus_(2).pdf

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Water Purification Chemical - Food Grade Granular Salt
Solicitation number
2026-03
Issued by
Essex County, New Jersey

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This is a Certification of Noninvolvement in Prohibited Activities in Russia or Belarus form required by New Jersey state law (N.J.S.A. 52:32-60.1, et seq.) 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 or other obligations. The certification applies to all vendors, defined broadly to include natural persons, corporations, partnerships, limited liability companies, governmental entities, and any parent, successor, subunit, or subsidiary of such entities. Vendors must certify their status regarding identification on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, which is accessible at https://sanctionssearch.ofac.treas.gov/. The form requires vendors to complete contact information fields including name, Federal Employer Identification Number (FEIN), address, phone number, fax number, and email address.

Vendors must select one of three certification options: confirming they are not identified on the OFAC list due to Russia and/or Belarus-related activity; stating they are unable to certify due to such identification; or confirming identification on the OFAC list but asserting that their Russia and/or Belarus-related activities are consistent with federal law, regulation, license, or exemption. The form must be executed by an authorized representative of the vendor and include the printed name and title of that representative along with the signature date. The Department of the Treasury is authorized to take enforcement action against vendors making false certifications, including imposing sanctions, seeking compliance, recovering damages, declaring the party in default, or seeking debarment or suspension. Failure to comply with this certification requirement may result in contract ineligibility or termination.

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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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