DisclosureofProhibitedActivitesinRussiaBelarus_(2).pdf
PDF 170 KB Posted
- Attached to
- Family Fun Day 2026
- Solicitation number
- 2026-008
- Issued by
- Essex County, New Jersey
About this file
This is a Certification of Noninvolvement in Prohibited Activities form issued by the State of New Jersey pursuant to N.J.S.A. 52:32-60.1, applicable to any vendor seeking to enter into or renew a contract with a New Jersey state agency. The certification requires vendors to confirm their status on the Office of Foreign Assets Control (OFAC) Specially Designated Nationals and Blocked Persons list, specifically regarding activities related to Russia and/or Belarus. Vendors must select one of three certification options: confirming non-identification on the OFAC list due to Russia/Belarus activity; stating inability to certify due to identification on the OFAC list for Russia/Belarus activity; or providing documentation that any Russia/Belarus-related activity complies with federal law, regulation, license, or exemption. The form requires completion with vendor identification information including legal name, Federal Employer Identification Number (FEIN), phone number, fax number, email address, street address, and city/state/zip code, along with signature and date authentication from an authorized vendor representative.
The certification applies broadly to all vendors, defined 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. The New Jersey Department of the Treasury retains enforcement authority and may impose sanctions, seek compliance, recover damages, declare the party in default, or pursue debarment or suspension for vendors making false certifications. The form references the OFAC sanctions search database available at https://sanctionssearch.ofac.treas.gov/ and directs vendors to review the referenced legislation (L. 2022, c. 3) prior to submission.
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Other files
| File | Type | Posted |
|---|---|---|
| Family_Fun_Day_2026.pdf | ||
| Family_Fun_Day_2026.pdf | ||
| Federal_Debarment_Form.pdf | ||
| DisclosureofProhibitedActivitesinRussiaBelarus_(2).pdf | ||
| Federal_Debarment_Form.pdf | ||
| Vendor_Submission_Forms_(2025).pdf | ||
| Disclosure_of_Iran_Investments.docx | DOCX document | |
| Vendor_Submission_Forms_(2025).pdf | ||
| W-9_(March2024)_(5).pdf | ||
| W-9_(March2024)_(5).pdf | ||
| Disclosure_of_Iran_Investments.docx | DOCX document |
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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. (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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