Exhibit K - New Jersey Chapter 51 Vendor Certification and Disclosure of Political Contributions.pdf

EXHIBIT F

State of New Jersey Two-Year Chapter 51/Executive Order 117 Vendor

Certification and Disclosure of Political Contributions

FOR STATE AGENCY USE ONLY

Solicitation, RFP, or Contract No. Award Amount

Description of Services

State Agency Name Contact Person

Phone Number Contact Email

Check if the Contract / Agreement is Being Funded Using FHWA Funds

Please check if requesting

Part 1: Business Entity Information recertification □

Full Legal Business Name (Including trade name if applicable)

Address

City State Zip Phone

Vendor Email Vendor FEIN (SS# if sole proprietor/natural person)

Check off the business type and list below the required information for the type of business selected.

MUST BE COMPLETED IN FULL

□ Corporation: LIST ALL OFFICERS and any 10% and greater shareholder

□ Professional Corporation: LIST ALL OFFICERS and ALL SHAREHOLDERS

□ Partnership: LIST ALL PARTNERS with any equity interest

□ Limited Liability Company: LIST ALL MEMBERS with any equity interest

□ Sole Proprietor

Note: “Officers” means President, Vice President with senior management responsibility, Secretary, Treasurer, Chief Executive Officer or Chief Financial Officer of a corporation, or any person routinely performing such functions for a corporation.

All Officers of a Corporation or PC 10% and greater shareholders of a corporation or all shareholders of a PC

All Equity partners of a Partnership All Equity members of a LLC

If you need additional space for listing of Officers, Shareholders, Partners or Members, please attach separate page.

IMPORTANT NOTE: You must review the definition of “contribution” and “business entity” on the

Information and Instructions form prior to completing Part 2 and Part 3. The Information and Instructions form is available at: http://www.nj.gov/treasury/purchase/forms/eo134/Chapter51.pdf

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K http://www.nj.gov/treasury/purchase/forms/eo134/Chapter51.pdf Walter Lewis

Part 2: Disclosure of Contributions by the business entity or any person or entity whose contributions are attributable to the business entity.

1. Report below all contributions solicited or made during the 4 years immediately preceding the commencement of negotiations or submission of a proposal to any:

Political organization organized under Section 527 of the Internal Revenue Code and which also meets the definition of a continuing political committee as defined in N.J.S.A. 19:44A-20.13 (See Information and Instructions form.)

2. Report below all contributions solicited or made during the 5 ½ years immediately preceding the

Candidate Committee for or Election Fund of any Gubernatorial or Lieutenant Gubernatorial candidate State Political Party Committee County Political Party Committee

3. Report below all contributions solicited or made during the 18 months immediately preceding the

Municipal Political Party Committee Legislative Leadership Committee

□Check this box only if no political contributions have been solicited or made by the business entity or any person or entity whose contributions are attributable to the business entity.

Part 3: Certification

(A) □ I am certifying on behalf of the business entity and all individuals and/or entities whose contributions are attributable to the business entity as listed on Page 1 under Part 1: Vendor Information.

(B) □ I am certifying on behalf of the business entity and all individuals and/or entities whose contributions are attributable to the business entity as listed on Page 1 under Part 1: Vendor Information, except for the individuals and/or entities who are submitting separate Certification and Disclosure forms which are included with this submittal.

(C) I am certifying on behalf of the business entity only; any remaining persons or entities whose contributions are attributable to the business entity (as listed on Page 1) have completed separate Certification and Disclosure forms which are included with this submittal.

(D) □ I am certifying as an individual or entity whose contributions are attributable to the business entity.

I hereby certify as follows:

1. I have read the Information and Instructions accompanying this form prior to completing the certification on behalf of the business entity.

2. All reportable contributions made by or attributable to the business entity have been listed above.

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Full Legal Name of Recipient

Address of Recipient of Contribution Amount of Contribution of Contribution (i.e. currency, check, loan, in-kind)

Name

Relationship of Contributor to the Vendor If this form is not being completed electronically, please attach additional contributions on separate page.

Remove Contribution

Click the “Add a Contribution” tab to enter additional contributions.

3. The business entity has not knowingly solicited or made any contribution of money, pledge of contribution, including in-kind contributions, that would bar the award of a contract to the business entity unless otherwise disclosed above:

a) Within the 18 months immediately preceding the commencement of negotiations or submission of a proposal for the contract or agreement to:

(i) A candidate committee or election fund of any candidate for the public office of Governor or Lieutenant

Governor or to a campaign committee or election fund of holder of public office of Governor or Lieutenant Governor; OR

(ii) Any State, County or Municipal political party committee; OR (iii)Any Legisative Leadership committee.

b) During the term of office of the current Governor or Lieutenant Governor to:

(i) A candidate committee or election fund of a holder of the public office of Governor or Lieutenant Governor;

OR

(ii) Any State or County political party committee of the political party that nominated the sitting Governor or

Lieutenant Governor in the last gubernatorial election.

c) Within the 18 months immediately preceding the last day of the sitting Governor or Lieutenant Governor’s first term of office to:

(i) A candidate committee or election fund of the incumbent Governor or Lieutenant Governor; OR

(ii) Any State or County political party committee of the political party that nominated the sitting Governor or

Lieutenant Governor in the last gubernatorial election.

4. During the term of the contract/agreement the business entity has a continuing responsibility to report, by submitting a new Certification and Disclosure form, any contribution it solicits or makes to:

(a) Any candidate committee or election fund of any candidate or holder of the public office of Governor or Lieutenant Governor; OR

(b) Any State, County or Municipal political party committee; OR

(c) Any Legislative Leadership committee.

The business entity further acknowledges that contributions solicited or made during the term of the contract/agreement may be determined to be a material breach of the contract/agreement.

5. During the two-year certification period the business entity will report any changes in its ownership structure (including the appointment of an officer within a corporation) by submitting a new Certification and Disclosure form indicating the new owner(s) and reporting said owner(s) contributions.

I certify that the foregoing statements in Parts 1, 2 and 3 are true. I am aware that if any of the statements are willfully false, I may be subject to punishment.

Signed Name Print Name

Title/Position Date

Procedure for Submitting Form(s)

The contracting State Agency should submit this form to the Chapter 51 Review Unit when it has been required as part of a contracting process. The contracting State Agency should submit a copy of the completed and signed form(s), to the Chapter 51 Unit and retain the original for their records.

The business entity should return this form to the contracting State Agency. The business entity can submit this form directly to the Chapter 51 Review Unit only when it -

• Is approaching its two-year certification expiration date and wishes to renew certification;

• Had a change in its ownership structure; OR

• Made any contributions during the period in which its last two-year certification was in effect, or during the term of a contract with a State Agency.

Forms should be submitted either electronically to: cd134@treas.nj.gov, or regular mail at:

Chapter 51 Review Unit, P.O. Box 230, 33 West State Street, Trenton, NJ 08625.

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