T1165 Chapter 51 Form 4.27.22~1.pdf

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INFORMATION AND INSTRUCTIONS

For Completing the “Two-Year Vendor Certification and Disclosure of Political Contributions” Chapter 51 Form Chapter 51 Instr. - Rev. 4/1/19 Background Information On September 22, 2004, then-Governor James E. McGreevey issued E.O . 1 34, the purpose of which was to insulate the negotiation and award of State contracts from political contributions that posed a risk of improper influence, purchase of access or the appearance thereof. To this end, E O 134 prohibited State departments, agencies and authorities from entering into contracts exceeding $17,500 with individuals or entities that made certain political contributions. E.

O was superseded by Public Law 2005, c. 51, signed into law on March 22, 2005 (“Chapter 51”).

On September 24, 2008, Governor Jon S. Corzine issued E O which is designed to enhance New Jersey’s efforts to protect the integrity of procurement decisions and increase the public’s confidence in government. The Executive Order builds upon the provisions of Chapter 51.

Two-Year Certification Process Upon approval by the State Chapter 51 Review Unit, the Certification and Disclosure of Political Contributions form is valid for a two (2) year period. Thus, if a vendor receives approval on Jan uary 1, 2014, the certification expiration date would be Dec ember 31, 2015. Any change in the vendor’s ownership status and/or political contributions during the two-year period will require the submission of new Chapter 51/E xecutive Order 117 forms to the State Review Unit.

Please note that it is the vendor’s responsibility to file new forms with the State should these changes occur.

State Agency Instructions: Prior to the awarding of a contract, the State Agency should first use NJSTART (https://www.njstart.gov/bso/) to check the status of a vendor’s Chapter 51 certification before contacting the Review Unit’s mailbox at CD134@treas.nj.gov. If the State Agency does not find any Chapter 51 Certification information in NJSTART and/or the vendor is not registered in NJSTART, then the State Agency should send an e-mail to CD134@treas.nj.gov to verify the certification status of the vendor. If the response is that the vendor is NOT within an approved two-year period, then forms must be obtained from the vendor and forwarded for review. If the response is that the vendor is within an approved two-year period, then the response so stating should be placed with the bid/contract documentation for the subject project.

Instructions for Completing the Form Part 1: BUSINESS ENTITY INFORMATION Business Name – Enter the full legal name of the vendor, including trade name if applicable.

Address, City, State, Zip and Phone Number -- Enter the vendor's street address, city, state, zip code and telephone number.

Vendor Email – Enter the vendor’s primary email address.

Vendor FEIN – Please enter the vendor’s Federal Employment Identification Number.

Business Type Check the appropriate box that represents the vendor's type of business formation.

Listing of officers, shareholders, partners or members - Based on the box checked for the business type, provide the corresponding information. (A complete list must be provided.)

Chapter 51 Instr. - Rev. 4/1/19

NOTE:

If form is being completed electronically, click "Add a Contribution" to enter additional contributions.

Otherwise, please attach additional pages as necessary.

Check Box A if the representative completing the Certification and Disclosure form is doing so on behalf of the business entity and all individuals and/or entities whose contributions are attributable to the business entity.

(No additional Certification and Disclosure forms are required if BOX A is checked.)

Check Box C if the representat i ve completing the Certification and Disclosure form is doing so on behalf of the business entity only.

(Additional Certification and Disclosure forms are required from all individuals and/or entities whose contributions are attributable to the business entity and must be included with the business entity submittal.)

Read the five statements of certification prior to signing.

(Additional Certification and Disclosure forms are required from those individuals and/or entities Part 2: DISCLOSURE OF CONTRIBUTIONS Read the three types of political contributions that require disclosure and if applicable, provide the recipient's information. The definition of " B usiness E ntity /Vendor and "Contribution" can be found on page s and 4 of this form.

Date of Contribution

- Indicate the date the contribution was given.

Amount of Contribution

- Enter the dollar amount of the contribution.

Contributor's Name - Enter the full name of the contributor.

Check Box B if the representative completing the Certification and Disclosure form is doing so on behalf of the business entity and all individuals and/or entities whose contributions are attributable to the business entity with the exception of those individuals and/or entities that submit their own separate form. For example, the representative is not signing on behalf of the v ice p resident of a corporation, but all others. The vice president completes a separate Certification and Disclosure form.

that the representative is not signing on behalf of and are included with the business entity's submittal.)

Part 3: CERTIFICATION Name of Recipient

- Enter the full legal name of the recipient.

Type of Contribution

- Select the type of contrib u t i on from the examples given.

Check the box under the recipient information if no reportable contributions have been solicited or made by the business entity.

This box must be checked if there are no contributions to report.

Check Box D when a sole proprietor is completing the Certification and Disclosure form or when an individual or entity whose contributions are attributable to the business entity is completing a separate Certification and Disclosure form.

Address of Recipient

- Enter the recipient's street address.

The representative authorized to complete the Certification and Disclosure form must sign and print her/his name, title or position and enter the date.

Relationship of the Contributor to the Vendor

- Indicate the relationship of the contributor to the vendor. (e.g.

officer or shareholder of the company, partner, member, parent company of the vendor, subsidiary of the vendor, etc.)

Chapter 51 Instr. - Rev. 4/1/19 The State Agency should submit the completed and signed Two-Year Vendor Certification and Disclosure forms 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 08625-0230. Original forms should remain with the State Agency and copies should be sent to the Chapter 51 Review Unit.

Business Entity Procedure for Submitting Form(s) State Agency Procedure for Submitting Form(s) The business entity should return this form to the contracting State Agency.

The business entity can submit the Certification and Disclosure form directly to the Chapter 51 Review Unit only when:

The business entity is approaching its two-year certification expiration date and is seeking certification renewal;

The business entity had a change in its ownership structure; OR The business entity 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.

Questions & Information Questions regarding Public Law 2005, Chapter 51 (N.J.S.A. 19:44A-20.13) or E.O. 117 (2008) may be submitted electronically through the Division of Purchase and Property website at: https://www.state.nj.us/treas/purchase/eo134questions.shtml.

Reference materials and forms are posted on the Political Contributions Compliance website at: http://www.state.nj.us/treasury/purchase/execorder134.shtml.

11.0.0.20130303.1.892433 Division of Purchase and Property Division of Purchase and Property Two-Year Chapter 51/Executive Order 117 Vendor Certification and Disclosure of Political Contributions

FOR STATE USE ONLY

Solicitation, RFP, or Contract No.___________________________ Award Amount______________________ Description of Services ____________________________________________________________ State Agency Name ________________________Contact Person __________________________________ Phone Number ____________________________Contact Email ___________________________________ 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.

Chapter 51 - Rev. 4/1/19 (If the corporation only has one officer, please write “sole officer” after the officer's name.)

Also Note: “N/A will not be accepted as a valid response. Where applicable, indicate “None.”

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-3(n) 2.

Report below all contributions solicited or made during the 5 ½ years immediately preceding the commencement of negotiations or submission of a proposal to any:

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 commencement of negotiations or submission of a proposal to any:

Municipal Political Party Committee Legislative Leadership Committee Full Legal Name of Recipient ________________________________________________________________ Address of Recipient ______________________________________________________________________ Date of Contribution __________________________ Amount of Contribution _________________________ Type of Contribution (i.e. currency, check, loan, in-kind) __________________________________________ Contributor Name _________________________________________________________________________ Relationship of Contributor to the Vendor _______________________________________________________ If this form is not being completed electronically, please attach additional contributions on separate page.

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

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 (Check one box only) (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.

Chapter 51 - Rev. 4/1/19 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:

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

cd134@treas.nj.gov Chapter 51 - Rev. 4/1/19 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:

3.

, or regular mail at: