T0167 Disclosure of Investigations Form 10.16.20~1.pdf

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

DISCLOSURE OF INVESTIGATIONS AND OTHER ACTIONS INVOLVING THE VENDOR FORM

BID SOLICITATION #: VENDOR:

PART 1

PLEASE LIST ALL OFFICERS/DIRECTORS OF THE VENDOR BELOW.

IN PART 2 OF THIS FORM, YOU WILL BE REQUIRED TO ANSWER QUESTIONS REGARDING THESE INDIVIDUALS.

OFFICERS/DIRECTORS

NAME

TITLE

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

NAME

TITLE

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

NAME

TITLE

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

Attach Additional Sheets If Necessary.

PART 2

PLEASE COMPLETE THE QUESTIONS BELOW BY CHECKING EITHER “YES” OR “NO”.

PLEASE REFER TO THE PERSONS LISTED ABOVE AND/OR THE PERSONS AND/OR ENTITIES LISTED ON

THE OWNERSHIP DISCLOSURE FORM WHEN ANSWERING THESE QUESTIONS.

YES NO

1. Has any person or entity listed on this form or its attachments ever been arrested, charged, indicted, or convicted in a criminal or disorderly persons matter by the State of New Jersey (or political subdivision thereof), or by any other state or the U.S. Government?

2. Has any person or entity listed on this form or its attachments ever been suspended, debarred or otherwise declared ineligible by any government agency from bidding or contracting to provide services, labor, materials or supplies?

3. Are there currently any pending criminal matters or debarment proceedings in which the firm and/or its officers and/or managers are involved?

4. Has any person or entity listed on this form or its attachments been denied any license, permit or similar authorization required to engage in the work applied for herein, or has any such license, permit or similar authorization been revoked by any agency of federal, state or local government?

5. Has any person or entity listed on this form or its attachments been involved as an adverse party to a public sector client in any civil litigation or administrative proceeding in the past five (5) years?

IF ANY OF THE ANSWERS TO QUESTIONS 1-5 ARE “YES”, PLEASE PROVIDE THE REQUESTED INFORMATION IN PART 3.

IF ALL OF THE ANSWERS TO QUESTIONS 1-5 ARE “NO”, NO FURTHER ACTION IS NEEDED; PLEASE SIGN AND DATE THE FORM.

DPP Rev. 3.15.19 Page 1 of 2

PART 3

PROVIDING ADDITIONAL INFORMATION

If you answered “YES” to any of questions 1 - 5 above, you must provide a detailed description of any investigation or litigation, including, but not limited to, administrative complaints or other administrative proceedings involving public sector clients during the past five (5) years. The description must include the nature and status of the investigation, and for any litigation, the caption of the action, a brief description of the action, the date of inception, current status, and if applicable, the disposition.

PERSON OR

ENTITY NAME

CONTACT NAME PHONE NUMBER

CASE CAPTION

INCEPTION OF THE

INVESTIGATION CURRENT STATUS

SUMMARY OF

INVESTIGATION

PERSON OR

ENTITY NAME

CONTACT NAME PHONE NUMBER

CASE CAPTION

INCEPTION OF THE

INVESTIGATION CURRENT STATUS

SUMMARY OF

INVESTIGATION

PERSON OR

ENTITY NAME

CONTACT NAME PHONE NUMBER

CASE CAPTION

INCEPTION OF THE

INVESTIGATION CURRENT STATUS

SUMMARY OF

INVESTIGATION

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

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