manchester Microsoft Word - 2021 Traffic Engineer RFP.pdf

PROJECT MANUAL

for

CC# 26-14

COMPETITIVE CONTRACT

5G WIRELESS CONSULTANT SERVICES

Manchester Township, Ocean County, N.J.

September 22, 2026, at 10:00am

Competitive Contract Request for Proposals

Notice is hereby given by the Township of Manchester that a Competitive Contract in accord with N.J.S.A.

40A:11-4.1 will be received by the Township on September 22, 2026, at 10:00am prevailing time conducted on electronic platform, in accord with N.J.A.C. 5:34-1 et. Seq., on BIDNET at www.bidnetdirect.com//ManchesterTwp

CC# 26-14 5G Wireless Consultant

NOTE:

It is the bidder’s responsibility to ensure that the bid package is uploaded onto the e-procurement site by the bid opening date and time. Any bid document received after the deadline established by the

Department of Purchasing will not be accepted, regardless of the method of delivery.

Bidders must comply with the requirements of N.J.S.A. 10:5-31 et seq., and

N.J.A.C. 17:27 et. Seq., The Township of Manchester will award this Competitive Contract in accord with Price and Other Factors as outlined within N.J.S.A 40A:11-4.1 et. Seq., and N.J.A.C. 5:34-4.1 et. Seq., Report of Competitive Contract:

In accord with N.J.S.A. 40A:11-4.4(d) the summary report will be posted on the Township procurement website at www.bidnetdirect.com//ManchesterTwp at least 48 hours prior to the governing body taking action on award.

This procurement has been advertised in accordance with the “Fair and Open Basis” (N.J.S.A. 19:44A-20.5).

Date: August 25, 2026 Carl Block

Business Administrator

Applicable to Bid if marked “X”

DOCUMENTATION REQUIRED OR

REVIEWED

Initials

When Due, if not with Bid

Submission

Bid Guarantee (Bid Bond or Certified/Cashier’s Check) (with POA for full amount of Bid Bond)

With Bid

Submission

Consent of Surety (Certificate from Surety company)

Submission

X Performance Bond and Labor and Material Payment Bond (Required from the Awarded Contractor)

At signing of contract

Maintenance Bond in the Amount of 100 % for a period indicated in

“General Conditions” Required from the Awarded Contractor Upon

Acceptance of Project

Upon

Acceptance of

Project

Acknowledgement of Receipt of Addenda (To be Completed if

Addenda are Issued)

With Bid

Submission

X Ownership Disclosure Form

Named Subcontractors in Bid for Listed Specialty Trades

Public Works Contractor Registration Certificate(s) for the Bidder and all Subcontractors

Prior to Award, but effective at time of bid

X

Business Registration Certificate – Bidder and all Subcontractors

Prior to

Contract Award

X Non-Collusion Affidavit With Bid

Submission

X Experience and Qualifications

Insurance and Indemnification Certificate

Contract Award

Disclosure of Investment Activities in Russia Form

Disclosure of Investment Activities in Iran Form

Award, Prior to

Signing

EEO/AA Form AA-302 or Letter of Federal Approval or

Certificate of Employee Information Report

After Notice of

Award, Prior to

Signing Contract

X Bidder’s Checklist

This checklist is provided for bidder’s use in assuring compliance with required documentation; however, it does not include all specifications requirements and does not relieve the bidder of the need to read and comply with the specifications.

Bidder

Name:

Date:

Authorized

Representative:

Signature:

Print Name &

Title:

1.0 PURPOSE:

The Township of Manchester is seeking a Telecommunications Consultant for a one (1) year appointment with an option to extend for an additional one (1) year, well versed in municipal process and application reviews for

5G expansion in the Township of Manchester.

The Consultant will be reliable in performing application and other consultant related tasks on behalf of the Township in interacting with cellular telecommunications companies requesting permits to expand their 5G network.

2.0 METHOD OF AWARD

2.1 This procurement is being conducted via the New Jersey Local Public Contracts Law (N.J.S.A.

40A:11-4.1 et. Seq.,) competitive contracting process.

2.2 The award shall be provided to the Consultant found to be the most advantageous to the

Township of Manchester based upon price and other factors.

2.3 The factors considered by the Township shall be weighted (weighting announced at time of procurement public opening) for the following categories:

2.3.1 Managerial capability 40%

2.3.2 Technical capability 40%

2.3.3 Cost Factors 20%

3.0 SCOPE OF DUTIES

3.1 This procurement is seeking a proposal that is a comprehensive document that will describe each of the consultants’ capabilities, experience and costs, within that document, the proposer shall:

3.2 Act on behalf of the Township of Manchester in response to applications for 5G service submitted to Township of Manchester.

3.3 Review existing and potential future actions as well as best practices.

3.4 Evaluate applications under the Small Wireless Facility Siting Permit or other related requirements

3.4.1 Be available for meetings with the Township Administrators Office, Engineering and

Construction Office staff or the Governing Body to provide for direction in response to applications or general telecommunication 5G build outs.

3.5 Review all right of way use agreements

3.6 Review and provide direction on existing utility poles and proposed smart poles.

3.7 Provide for consulting at the request of the Township on case-by-case basis as required for areas outside of the application process if requested.

3.8 Other services as may be required:

3.9 Make recommendations for improvements of telecommunications.

3.10 Recommend the steps to accomplish the needed changes if any.

4.0 BILLING/ RATES

4.1 Consultants shall in all assigned consulting reviews provide for:

4.1.1 Activity log reflecting activity and billing in ¼ hour increments

4.1.2 Provide for detailed travel if any.

4.1.3 Provide for monthly billing statements broken out by project/ applicant for ease of review in paying through escrow.

5.0 PROPOSAL RATES:

5.1 Consultants are to respond with full rate charges, including but not limited to:

5.1.1 Rate per hour application reviews:

5.1.1.1 Minimum hours:

5.1.2 Travel Rates/ Costs:

5.1.2.1 Minimum hours travel if any

5.1.3 Other charges and rates as proposed

5.1.4 Increases in rates by percent if any over years of this contract.

6.0 EXPERIENCE (Managerial & Technical)

6.1 The proposer must provide information about past experience with other clients to show proven and demonstrated ability to execute the requirements of the competitive contract.

6.2 The proposal must include five specific references of similar accounts/ experience, Information about each shall be presented in this format:

6.2.1 Name of the business that was serviced

6.2.2 Contact name

6.2.3 Address

6.2.4 Phone Number

6.2.5 Email Address

6.2.6 Amount of the contract

6.2.7 Description of the contract

6.2.8 Date the contract began

6.2.9 Date the contract ended (if applicable)

6.3 Municipal experience in providing for similar analysis, high level application review and process as Township Manager, Planning and Zoning Engineer, Construction Official may substitute, provided that experience is well documented as at Section 6.2.

7.0 RATING MATRIX

7.1 The below is a sample of the rating matrix to be used by the Competitive Contract Review

Committee:

As per N.J.A.C. 5:34-1 et. Seq., the rating report will be made available at a minimum of 48 hours

PRIOR to action by the Governing Body in any future award for this service.

The Rating sheet below is the matrix the rating committee will be utilizing to rate respondents. Weighed criteria will be announced at the Competitive Contract opening.

ALL QUESTIONS AND BID SUBMITTALS MUST GO THROUGH

www.bidnetdirect.com//manchestertwp

AGREEMENT TO HOLD PRICES

A. The vendor by signing below agrees as per N.J.S.A 40A:11-24(a) to hold prices until January 31, 2027.

40A:11-24(a). a. The contracting unit shall award the contract or reject all bids within such time as may be specified in the invitation to bid, but in no case more than 60 days, except that the bids of any bidders who consent thereto may, at the request of the contracting unit, be held for consideration for such longer period as may be agreed.

Vendor Date

Technical criteria: NAME OF RATER:

(Max Points ) 1 Pt = Poor Response, 3 Points = Average Response, 5

Pts = Concise and Superior

Response

Vendor Name:

(1)Does the vendor's proposal demonstrate a clear understanding of the scope of work and related objectives?

(2)Is the vendor's proposal compared to the others superior in completeness and responsiveness to the specific RFP requirements found in the scope of work?

(3) Has the past performance of the vendor's proposed methodology been documented to a superior degree?

(4) Does the vendor's proposal use innovative technology and techniques?

Sub Total Technical 0 0

Management criteria:

3 Points = Average Response, 5

(1) Does the vendor document a record of reliability of timely delivery and on-time and on- budget implementation?

(2) Does the vendor document industry or program experience?

(3) Are the availability of in- house and contract resources documented?

Sub Total Managerial 0 0

Cost criteria:

3 Points = Average Response, 5

(1) Relative cost: How does the cost compare to other similarly scored proposals?

(2) Full explanation:

Is the price and its component charges, fees, etc. adequately explained or documented?

(3) Does the proposal include quality control and assurance programs?

SUB TOTAL COST 0 0

Total Points Technical + Managerial + Cost 0 0

EXHIBIT A

MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE

N.J.S.A. 10:5‐31 et seq. (P.L.1975, c.127)

N.J.A.C. 17:27 et seq.

GOODS, GENERAL SERVICES, AND PROFESSIONAL SERVICES CONTRACTS

During the performance of this contract, the contractor agrees as follows:

The contractor or subcontractor, where applicable, will not discriminate against any employee or applicant for employment because of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex. Except with respect to affectional or sexual orientation and gender identity or expression, the contractor will ensure that equal employment opportunity is afforded to such applicants in recruitment and employment, and that employees are treated during employment, without regard to their age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

Such equal employment opportunity shall include, but not be limited to the following: employment, upgrading, demotion, or transfer; recruitment or recruitment advertising; layoff or termination; rates of pay or other forms of compensation; and selection for training, including apprenticeship.

The contractor agrees to post in conspicuous places, available to employees and applicants for employment, notices to be provided by the Public Agency Compliance Officer setting forth provisions of this nondiscrimination clause.

The contractor or subcontractor, where applicable will, in all solicitations or advertisements for employees placed by or on behalf of the contractor, state that all qualified applicants will receive consideration for employment without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex.

The contractor or subcontractor will send to each labor union, with which it has a collective bargaining agreement, a notice, to be provided by the agency contracting officer, advising the labor union of the contractor's commitments under this chapter and shall post copies of the notice in conspicuous places available to employees and applicants for employment.

The contractor or subcontractor, where applicable, agrees to comply with any regulations promulgated by the Treasurer pursuant to N.J.S.A. 10:5‐31 et seq., as amended and supplemented from time to time and the Americans with Disabilities Act.

The contractor or subcontractor agrees to make good faith efforts to meet targeted county employment goals established in accordance with N.J.A.C. l7:27‐5.2.

The contractor or subcontractor agrees to inform in writing its appropriate recruitment agencies including, but not limited to, employment agencies, placement bureaus, colleges, universities, and labor unions, that it does not discriminate on the basis of age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, and that it will discontinue the use of any recruitment agency which engages in direct or indirect discriminatory practices.

The contractor or subcontractor agrees to revise any of its testing procedures, if necessary, to assure that all personnel testing conforms with the principles of job related testing, as established by the statutes and court decisions of the State of New Jersey and as established by applicable Federal law and applicable Federal court decisions.

In conforming with the targeted employment goals, the contractor or subcontractor agrees to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that all such actions are taken without regard to age, race, creed, color, national origin, ancestry, marital status, affectional or sexual orientation, gender identity or expression, disability, nationality or sex, consistent with the statutes and court decisions of the

State of New Jersey, and applicable Federal law and applicable Federal court decisions. The contractor shall submit to the public agency, after notification of award but prior to execution of a goods and services contract, one of the following three documents:

Letter of Federal Affirmative Action Plan Approval; Certificate of Employee Information

Report; or

Employee Information Report Form AA‐302 (electronically provided by the Division and distributed to the public agency through the Division’s website at: http:// www.state.nj.us/treasury/contract_compliance.

The contractor and its subcontractors shall furnish such reports or other documents to the Division of

Purchase & Property, CCAU, EEO Monitoring Program as may be requested by the office from time to time in order to carry out the purposes of these regulations, and public agencies shall furnish such information as may be requested by the Division of

Purchase & Property, CCAU, EEO Monitoring Program for conducting a compliance investigation pursuant to N.J.A.C. 17:27‐1.1 et seq.

NEW JERSEY ANTI-DISCRIMINATION PROVISIONS

N.J.S.A. 10:2-1 ET SEQ.

Pursuant to N.J.S.A. 10:2-1, if awarded a contract, the contractor agrees that:

a. In the hiring of persons for the performance of work under this contract or any subcontract hereunder, or for the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under this contract, no contractor, nor any person acting on behalf of such contractor or subcontractor, shall, by reason of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex, discriminate against any person who is qualified and available to perform the work to which the employment relates;

b. No contractor, subcontractor, nor any person on his behalf shall, in any manner, discriminate against or intimidate any employee engaged in the performance of work under this contract or any subcontract hereunder, or engaged in the procurement, manufacture, assembling or furnishing of any such materials, equipment, supplies or services to be acquired under such contract, on account of race, creed, color, national origin, ancestry, marital status, gender identity or expression, affectional or sexual orientation or sex;

c. There may be deducted from the amount payable to the contractor by the contracting public agency, under this contract, a penalty of $50.00 for each person for each calendar day during which such person is discriminated against or intimidated in violation of the provisions of the contract; and

d. This contract may be canceled or terminated by the contracting public agency, and all money due or to become due hereunder may be forfeited, for any violation of this section of the contract occurring after notice to the contractor from the contracting public agency of any prior violation of this section of the contract.

SAMPLE CERTIFICATE OF EMPLOYEE INFORMATION REPORT

New Jersey Business Registration Certification

Pursuant to N.J.S.A. 52:32-44, The Township of Manchester (“Contracting

Agency”) is prohibited from entering into a contract with an entity unless the bidder/proposer/contractor, and each subcontractor that is required by law to be named in a bid/proposal/contract has a valid Business Registration Certificate on file with the Division of Revenue and Enterprise Services within the Department of the Treasury.

Prior to contract award or authorization, the contractor shall provide the Contracting Agency with its proof of business registration and that of any named subcontractor(s).

Subcontractors named in a bid or other proposal shall provide proof of business registration to the bidder, who in turn, shall provide it to the Contracting Agency prior to the time a contract, purchase order, or other contracting document is awarded or authorized.

During the course of contract performance:

(1) the contractor shall not enter into a contract with a subcontractor unless the subcontractor first provides the contractor with valid proof of business registration.

(2) the contractor shall maintain and submit to the Contracting Agency a list of subcontractors and their addresses that may be updated from time to time.

(3) the contractor and any subcontractor providing goods or performing services under the contract, and each of their affiliates, shall collect and remit to the Director of the Division of Taxation in the Department of the Treasury, the use tax due pursuant to the Sales and Use Tax Act, (N.J.S.A. 54:32B-1 et seq.) on all sales of tangible personal property delivered into the State. Any questions in this regard can be directed to the Division of Taxation at (609)292- 6400. Form NJ-REG can be filed online at http://www.state.nj.us/treasury/revenue/busregcert.shtml.

Before final payment is made under the contract, the contractor shall submit to the Contracting Agency a complete and accurate list of all subcontractors used and their addresses.

Pursuant to N.J.S.A. 54:49-4.1, a business organization that fails to provide a copy of a business registration as required, or that provides false business registration information, shall be liable for a penalty of $25 for each day of violation, not to exceed $50,000, for each proof of business registration not properly provided under a contract with a contracting agency.

Emergency Purchases or Contracts

For purchases of an emergent nature, the contractor shall provide its Business Registration Certificate within two weeks from the date of purchase or execution of the contract or prior to payment for goods or services, whichever is earlier.

SAMPLE BUSINESS REGISTRATION CERTIFICATE

PAY TO PLAY ADVISORY

Disclosure Requirement

P.L. 2005, Chapter 271, Section 3 Reporting (N.J.S.A.

19:44A – 20.27)

Any business entity that has received $50,000 or more in contracts from government entities in a calendar year will be required to file an annual disclosure report with ELEC.

The report will include certain contributions and contract information for the current calendar year.

At a minimum, a list of all business entities that file an annual disclosure report will be listed on ELEC’s website at www.elec.state.nj.us.

If you have any questions please contact ELEC at: 1-888-313-

ELEC (toll free in NJ) or

609-292-8700

An analyst from ELEC’s Special Programs Section will assist you.

STATEMENT OF OWNERSHIP DISCLOSURE

N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)

This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal.

Name of Organization:

Organization Address:

Part I Check the box that represents the type of business organization:

Sole Proprietorship (skip Parts II and III, execute certification in Part IV)

Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)

For-Profit Corporation (any type) Limited Liability Company (LLC)

Partnership Limited Partnership Limited Liability Partnership (LLP)

Other (be specific):

Part II

The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION)

OR

No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV)

(Please attach additional sheets if more space is needed):

Name of Individual or Business Entity Address

Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS, PARTNERS OR

LLC MEMBERS LISTED IN PART II

If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10 percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal Security and Exchange

Commission (SEC) or foreign equivalent filing, ownership disclosure can be met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a 10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers of the filing(s) that contain the information on each such person. Attach additional sheets if more space is needed.

Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #’s

Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater interest in any corresponding corporation, partnership and/or limited liability company (LLC) listed in Part II other than for any publicly traded parent entities referenced above. The disclosure shall be continued until names and addresses of every noncorporate stockholder, and individual partner, and member exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed. Attach additional sheets if more space is needed.

Stockholder/Partner/Member and

Corresponding Entity Listed in Part II

Address

Part IV Certification

I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this certification on behalf of the bidder/proposer; that the Township is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the completion of any contracts with Township to notify the

Township in writing of any changes to the information contained herein; 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 am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township to declare any contract(s) resulting from this certification void and unenforceable.

Full Name (Print):

Title:

Signature:

Date:

Experience & Qualifications Questionnaire

This questionnaire must be filled out and submitted as a part of the Proposal. Failure to complete this form or to provide any of the requested information will be grounds for the rejection of the bid proposal. If additional space is required, the respondent shall add additional sheets, which identify the question being answered.

Number of years in business under present name & address:

If less than 5 years, list previous names and address:

Within the last 5 years has the business or any officer/partner failed to complete a contract awarded to them:

. If yes, provide the details on a separate page.

Have any liens and lawsuits been filed against the company in the past 5 years:

If yes, please provide details:

List similar services you are now providing for which you have signed contract, but not yet started work:

List all major subcontractors to be used to complete the service and the area of their responsibility:

Experience & Qualifications Questionnaire

Please provide at least 3 references below:

Name: Phone:

Address:

Equipment/Service Provided:

Contract Amount:

Expérience & Qualifications Questionnaire

Americans with Disabilities Act of 1990

The CONTRACTOR and the OWNER do hereby agree that the provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "ACT") (42 U.S.C~ S12101 et seq.), which prohibits discrimination on the basis of disability by public entities in all services, programs, and activities provided or made available by public entities, and the rules and regulations promulgated pursuant thereunto, are made a part of this contract. In providing any act benefit, or service on behalf of the OWNER pursuant to this contract, the

CONTRACTOR agrees that the performance shall be in strict compliance with the Act. In the event that the Contractor, its agents, servants, employees, or subcontractors violate or are alleged to have violated the Act during the performance of this contract, the

CONTRACTOR shall defend the OWNER in any action or administrative proceeding commenced pursuant to this Act. The Contractor shall indemnify, protect, and save harmless the OWNER, its agents, servants, and employees from and against any and all suits, claims, losses, demands, or damages, of whatever kind or nature arising out of or claimed to arise out of the alleged violation. The CONTRACTOR shall, at its own expense, appear, defend, and pay any and all charges for legal services and any and all costs and other expenses arising from such action or administrative proceeding or incurred in connection therewith. In any and all complaints brought pursuant to the OWNER grievance procedure, the CONTRACTOR agrees to abide by any decision of the OWNER which is rendered pursuant to said grievance procedure. If any action or administrative proceeding results in an award of damages against the OWNER or if the OWNER must any expense to cure a violation of the ADA which has been brought pursuant to its grievance procedure, the CONTRACTOR shall satisfy and discharge the same at its OWN expense.

The OWNER shall, as soon as practicable after a claim has been made against it, give written notice thereof to the CONTRACTOR along with frill and complete particulars of the claim. if any action or administrative proceedings is brought against the OWNER or any of its agents, servants, and employees, the OWNER shall expeditiously forward or have forwarded to the CONTRACTOR every demand, complaint, notice, summons, pleading, or other process received by the OWNER or its representatives.

It is expressly agreed and understood that any approval by the OWNER of the services provided by the CONTRACTOR pursuant to this contract will not relieve the

CONTRACTOR of the obligation to comply with the Act and to defend, indemnify, protect, and save harmless the OWNER pursuant to this paragraph.

It is further agreed and understood that the OWNER assumes no obligation to indemnify or save harmless the CONTRACTOR, its agents, servants, employees and subcontractors for any claim which may arise out of their performance of this Agreement. Furthermore, the CONTRACTOR expressly understands and agrees that the provisions of this indemnification clause shall in no way limit the CONTRACTOR'S obligations assumed in this Agreement, nor shall they be construed to relieve the CONTRACTOR from any liability, nor preclude the OWNER from taking any other actions available to it under any other provisions of the Agreement or otherwise at law.

CERTIFICATION OF NON‐INVOLVEMENT IN

PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS

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.

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.

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 (Township/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).

NJ Rev. 1.22.2024

DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN

FORM

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY - DIVISION OF PURCHASE AND

PROPERTY 33 WEST STATE STREET, P.O. BOX 230 TRENTON, NEW

JERSEY 08625-0230

BID SOLICITATION # AND TITLE:

VENDOR NAME:

Pursuant to N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4) any person or entity that submits a bid or proposal or otherwise proposes to enter into or renew a contract must certify that neither the person nor entity, nor any of its parents, subsidiaries, or affiliates, is identified on the New Jersey Department of the Treasury’s Chapter

25 List as a person or entity engaged in investment activities in Iran. The Chapter 25 list is found on the Division’s website at https://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. Vendors/Bidders must review this list prior to completing the below certification. If the Director of the Division of

Purchase and Property finds a person or entity to be in violation of the law, s/he shall take 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.

CHECK THE APPROPRIATE

BOX

I certify, pursuant to N.J.S.A. 52:32-57, et seq. (P.L. 2012, c.25 and P.L. 2021, c.4), that neither the Vendor/Bidder listed above nor any of its parents, subsidiaries, or affiliates is listed on the New Jersey Department of the Treasury’s Chapter 25 List of entities determined to be engaged in prohibited activities in Iran.

OR

I am unable to certify as above because the Vendor/Bidder and/or one or more of its parents, subsidiaries, or affiliates is listed on the New Jersey Department of the Treasury’s Chapter 25 List. I will provide a detailed, accurate and precise description of the activities of the Vendor/Bidder, or one of its parents, subsidiaries or affiliates, has engaged in regarding investment activities in Iran by completing the information requested below.

Entity Engaged in Investment Activities Relationship to Vendor/ Bidder

Description of Activities

Duration of Engagement

Anticipated Cessation Date

*Attach Additional Sheets If Necessary.

CERTIFICATION

I, the undersigned, certify that I am authorized to execute this certification on behalf of the

Vendor, that the foregoing information and any attachments hereto, to the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying on the information contained herein, and that the Vendor is under a continuing obligation from the date of this certification through the completion of any contract(s) with the State to notify the State in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do so, I may be subject to criminal prosecution under the law, and it will constitute a material breach of my contract(s) with the State, permitting the State to declare any contract(s) resulting from this certification void and unenforceable.

Signature Date

Print Name and Title

DPP Rev. 12.13.2021

NON COLLUSION AFFIDAVIT

STATE OF NEW JERSEY

I certify that I am _______________________________________________________________ of the firm of __________________________________________________________________ the Respondent making this Proposal for the bid or proposal for the above named project, that I executed the said proposal with full authority to do so; that said bidder has not, directly or indirectly entered into any agreement, participated in any collusion or otherwise taken any action in restraint of free, competitive bidding in connection with the above named project; and that all statements contained in said proposal and this affidavit are true, correct, and made with full knowledge that the

Township relies upon the truth of the statements contained in said Proposals and in the statements contained in this affidavit in awarding the contract for the said project.

I further warrant that no person or selling agency has been employed or retained to solicit or secure such contract upon an agreement or understanding for a commission, percentage, brokerage, or contingent fee, except bona fide employees or bona fide established commercial or selling agencies.

Signature of Representative:

Subscribed and sworn to before me this_________ day of ___________________, 20_______

Print Name of Affiant:___________________________________________________________

Notary Public of ____________________________

My commission expires_______________________

*This form MUST be completed, notarized and submitted with the bid document*