T2923Source Disclosure.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

SOURCE DISCLOSURE FORM

BID SOLICITATION #: VENDOR/BIDDER:

The Vendor/Bidder submits this form in response to a solicitation issued by the State of New Jersey, Department of the Treasury, Division of Purchase and Property (Division), in accordance with the requirements of N.J.S.A. 52:34-13.2.

INSTRUCTIONS

List every location where services will be performed by the Contractor and all Subcontractors. If any of the services cannot be performed within the United States, the Contractor shall state, with specificity, the reasons why the services cannot be performed in the United States.

Name of Contractor / Sub-contractor

Performance Location by Country

Description of Service(s) to be Performed Outside of the U.S.

Reason Why the Service(s) Cannot be Performed in the U.S.

The Contractor shall provide justification that the services cannot be performed in the United States by any Contractor. The Director of the Division of Purchase and Property will review this justification and if deemed sufficient, the Director may seek the Treasurer’s approval.

Any changes to the information set forth in this form during the term of any Contract awarded under the referenced solicitation or extension thereof will be immediately reported by the Contractor to the Director of the Division.

I, the undersigned, on behalf of the Contractor, understand that after award of the contract to the Contractor, if it is determined that the Contractor has shifted services declared above to be provided within the United States to sources outside the United States, prior to a written determination by the Director that circumstances require the shift of services or that the failure to shift services would result in economic hardship to the State of New Jersey, the Contractor shall be deemed in breach of contract, and the contract will be subject to termination for cause pursuant to the State of New Jersey Standard Terms and Conditions. I further understand that this form is submitted on behalf of the Contractor in order to induce the Division to accept a proposal, with the knowledge that the Division relies upon the truth of the statement contained herein.

CERTIFICATION

I, the undersigned, certify that I am authorized to execute this certification on behalf of the Vendor/Bidder, 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/Bidder 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 will be subject to criminal prosecution under the law, and it will constitute a material breach of my agreement(s) with the State, permitting the State to declare any contract(s) resulting from this certification to be void and unenforceable.

Signature Date

Print Name and Title

DPP Rev. 6.23.2017 Page 1 of 1