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Executive Summary
This document outlines the requirements for fair and open contracts with Barnegat Township, not to exceed $39,999.99 for Calendar Year 2019, as per N.J.S.A. 19:44A-20.4 et seq. It includes a checklist of required forms such as Non-Collusion Affidavit, New Jersey Business Registration, References, Affirmative Action Language, Americans with Disabilities Act Language, Insurance Certificates, Disclosure of Investment Activities in Iran, W-9 form, Fair & Open Contribution Prohibition Language, Business Entity Disclosure Form, Political Contribution Disclosure Certification and Stockholder Disclosure Statement. Bidders must comply with documentation requirements, and ensure compliance with regulations regarding business registration, equal employment opportunity, and political contributions.
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--- Document: Fair and Open contract forms Document ---
N??.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT DOCUMENT CHECKLIST"
H Read Only
€ Provide the Required Form(s)
*This form need not be submitted. It is provided for bidder's use in assuring compliance with
all required documentation.
BDC-1
Required
by owner
Submission Requirement
lnitial each
required entry
and if required
submit the item
a
Non-Collusion Affidavit - [Pg. P-1]
a
New Jersey Business Registration
(must be submitted prior to contract award) - [Pg. P-2]
a
References - [Pg. P-3]
a
Mandatory Affirmative Action Language (Pg. AA1 -AA2)
[Pg. P-4 & P-5]
s
Americans with Disabilities Act of 1990 Language
(Pg. AD-1 ) - [P-6]
a
Insurance Certificates - [P-7]
a
Disclosure of Investment - Activities in lran - [Pg. P-8 & P-9]
a
W-9 Request for Taxpayer ldentification Number and
Certification - [Pg. P-10
a
Fair & Open Contribution Prohibition Language
[Pg. P-1 1]
a
Business Entity Disclosure Form - [Pg. P-12 & P-13]
a
Political Contribution Disclosure Certification
[Pg. P-14 & P-17]
a
Stockholder Disclosure Statement - [Pg. P-18 & P-19]
a
Reporting to the Office of the New Jersey State Comptroller
[Pg. P-20
?N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
NON-COLLUSION STATEMENT
Upon request, the bidder will be expected to amplify the foregoing statements as necessary to
satisfy the Township concerning his ability to successfully perform the work in a satisfactory
manner.
The undersigned bidder submitting this proposal or bid certifies and affirms that such bid is
genuine and is not the result of collusion. Said bidder has not colluded, conspired, connived. or
agreed, directly or indirectly, with any bidder or person, to put in a false bid, or that such other
persons shall refrain from bidding. Said bidder has not in any manner, directly or indirectly, sought
by agreement or collusion, or communication or conference, with any person, to fix overhead, profit
or cost element of said bid price, or that of any other bidder, or to secure any advantage against
the Township or any person interested in the proposed contract. Further, such bidder has not,
directly or indirectly, submitted this bid, or the contents thereof, or divulged information or data
relative thereto to any association or to any member or agent thereof; and, that no Township
official or employee is interested directly or indirectly in the bid or in any portion of the bid, nor in
the contract or in any part of the contract which may be awarded the undersigned on the basis of
such bid.
Signed this
day of
(Bidder)
BV
Signature of Authorized Individual,
Partner or Officer Signing the Proposal
Print Name:
Title:
Date:
P-1
N?j??.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
BIIS?NFSS REGISTRATION CERTIF?CATE
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BI?SINESS REG?STRATION CERT?FICATE
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Reforms to the Business Registration Certificate Filing: permits filing prior to award of contracts if
not filed with bid. Effective with bids received and contracts awarded after January 18, 2010, this law
removes the requirement of the Local Public Contracts Law (N.J.S.A. 40A:11-23.2) that required a
bid to be rejected if the bidder failed to include a BRC with the bid, even though it may have been
the otherwise Iowest responsible bid. The Iaw now allows the BRC to be filed any time prior to
award of the contract and the bidder had to have obtained the BRC prior to receipt of bids. This
permits the BRC to be required with a bid, or submitted subsequently. If a BRC is required in a bid,
but not submitted with the bid, it would an immaterial defect; curable by being filed prior to award of
the contract. A BRC is obtained from the New Jersey Division of Revenue. Information on obtaining
a BRC is available on the internet at www.nj.gov/njbgs or by phone at (609) 292-1730.
N.J.S.A. 52:32-44 imposes the following requirements on contractors and all subcontractors that
knowingly provide goods or perform services for a contractor fulfilling this contract:
1) The contractor shall provide written notice to its subcontractors and suppliers to submit proof of
business registration to the contractor;
2) Subcontractors through all tiers of a project must provide written notice to their subcontractors
and suppliers to submit proof of business registration and subcontractors shall collect such
proofs of business registration and maintain them on file;
3) Prior to receipt of final payment from a contracting agency, a contractor must submit to the
contacting agency an accurate Iist of all subcontractors or attest that none was used;
4) During the term of this contract, the contractor and its affiliates shall collect and remit, and shall
notify all subcontractors and their affiliates that they must collect and remit to the Director, New
Jersey Division of Taxation, 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 this State.
A contractor, subcontractor or supplier who fails to provide proof of business registration or
provides false business registration information shall be liable to a penalty of $25 for each day of
violation, not to exceed $50,000 for each business registration not properly provided or maintained
under a contract with a contracting agency. Information on the Iaw and its requirements is available
by calling (609) 292-1730.
P-2
N?.. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
REFERENCES
Please Iist three (3) references below:
1.
2.
3.
Signature:
Print Name:
Title:
Date:
P-3
?N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
(REVISED 4/1 0)
TOWNSHIP OF BARNEGAT
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
GOODS, PROFESSIONAL SERVICE AND GENERAL SERVICE 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 Iimited 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. 17:27-5.2.
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.
P-4
??N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
(REVISED 4/1 0)
TOWNSHIP OF BARNEGAT
EXHIBIT A continued
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 to 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
*
Employee Information Report Form AA302 (electronically provided by the Division
and distributed to the public agency through the Division's website at
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 Subchapter 10 of the
Administrative Code at N.J.A.C. 17:27.
Company
Signature
Title
Date
P-s
N?j??.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
APPENDIX A
AMERICANS WITH DISABILITIES ACT OF 1990
Equal Opportunity for Individuals with Disability
The contractor and the Township of Barnegat, (hereafter "owner") do hereby agree that the
provisions of Title 11 of the Americans With Disabilities Act of 1990 (the "Act") (42 ?. 8121 01
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 there unto, are made a part of this contract. In providing any aid,
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's 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 incurs
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 full and complete particulars of the claim, If any action or
administrative proceeding 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.
Company
Signature
Title
Date
P-6
?.. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
INSURANCE CERTIF?CATES
Name of Bidder:
Address:
The Bidder is required to submit actual Certificate(s) of Insurance
establishing Insurance coverage of the type and amount required in
accordance with the procedure set forth by the Contract Documents.
(Documents to be submitted prior to the resolution of award)
a
1, GENERAL L?ABILITY INSURANCE
General liability insurance shall be provided with Iimits of not Iess than $1,000,000.00 any one
person and $1,000,000.00 any one accident for bodily injury and $1,000,000.00 aggregate for
property damage, and shall be maintained in full force during the Iife of the contract.
[I]
2. AUTOMOTIVE LIAB?LITY INSURANCE
Automotive Iiability insurance covering contractor for claims arising from owned, hired and non-
owned vehicles with limits of not less than $1,000,000.00 any one person and $1,000,000.00 any
one accident for bodily injury and $1,000,000.00 each accident for property damage, shall be
maintained in full force during the life of the contract.
P-7
?.. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
DISCLOSURE OF INVESTMENT ACTMTIES IN IRAN
l PART 1: CERTIFICATION
l
r
BIDDERS MUST COMPLETE PART I BY CHECKING EITHER BOX.
FAILURE TO CHECK ONE OF THE BOXES MAY RENDER THE PROPOSAL NON-RESPONSIVE.
1
Pursuant to Public Law 2012, c. 25, any person or entity that submits a bid or proposal or otherwise proposes to enter
into or renew a contract must complete the certification below to attest, under penalty of perjury, that neither the person
or entity, nor any of its parents, subsidiaries, or affiliates, is identified on the Department of Treasury's Chapter 25 Iist as
a person or entity engaging in investment activities in Iran. The Chapter 25 Iist is found on the State of New Jersey,
Department of Treasury, Division of Purchase and Property website at:
http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. Bidders must review this Iist prior to completing the
below certification. Failure to complete the certification may render a bidder's bid proposal non-responsive. If the
Township of Barnegat determines that a person or entity has submitted a false certification concerning its engagement in
investment activities in Iran pursuant to section 4 of P.L. 2012, c.25 (C.52:32-58), the Iocal contracting unit shall report to
the New Jersey Attorney General the name of that person or entity, and the Attorney General shall determine whether to
bring a civil action against the person to collect the penalty prescribed in paragraph (1 ) of subsection a. of section s of
P.L. 2012, c.25 (C.52:32-59). The Township of Barnegat may also report to the municipal attorney or county counsel, as
appropriate, the name of that person, together with its information as to the false certification, and the municipal attorney
or county counsel, as appropriate, may determine to bring such civil action against the person to collect such penalty.
PLEASE CHECK THE APPROPRIATE BOX:
€ l certify, pursuant to Public Law 2012, c. 25, that neither the bidder Iisted above nor any of the bidder's parents,
subsidiaries, or affiliates is Iisted on the N.J. Department of the Treasury's Iist of entities determined to be engaged in
prohibited activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25 List"). l further certify that l am the person Iisted
above, or I am an officer or representative of the entity listed above and I am authorized to rriake this certification on its
behalf. I will skip Part 2 and sign and complete the Certification below.
OR
€ I am unable to certify as above because the bidder and/or one or more of its parents, subsidiaries, or affiliates is
Iisted on the Department's Chapter 25 Iist. I will provide a detailed, accurate and precise description of the activities in
Part 2 below and sign and complete the Certification below. Failure to provide such will result in the proposal being
rendered as nonresponsive and appropriate penalties, fines and/or sanctions will be assessed as provided by Iaw.
!? PLEASE PROVIDE FURTHER INFORMATION RELATED TO INVESTMENT ACTMTIES IN IRAN
You must provide a detailed, accurate and precise description of the activities of the bidding person/entity, or
one of its parents, subsidiaries or affiliates, engaging in the investment activities in Iran outlined above by
completing the boxes below.
PROVIDE INFORMAT?ON RELATIVE TO THE ABOVE QUESTIONS. PLEASE PROVIDE THOROUGH ANSWERS
TO EACH QUESTION. IF YOU NEED TO MAKE ADDIT?ONAL ENTRIES, ATTACH ADD?TIONAL PAGES.
Name
Relationship to Bidder/Offeror
Description of Activities
Duration of Engagement
Anticipated Cessation Date
Bidder/Offeror Contact Name
Contact Phone Number
P-8
?N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP BARNEGAT
DISCLOSURE OF INVESTMENT ACTMTIES IN IRAN
iCertification:
l
I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments
thereto to the best of my knowledge are true and complete. I attest that I am authorized to execute this certification on
behalf of the above-referenced person or entity. I acknowledge that the Township of Barnegat is relying on the
information contained herein and thereby acknowledge that l am under a continuing obligation from the date of this
certification through the completion of any contracts with the Township of Barnegat to notify the Township of Barnegat
in writing of any changes to the answers of information contained herein. l acknowledge 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 recognize that l
am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s)
with the Township of Barnegat and that the Township of Barnegat at its option may declare any contract(s) resulting
from this certification void and unenforceable.
1, being duly sworn upon my oath, hereby represent and state that the foregoing information and
any attachments thereto to the best of my knowledge are true and complete. l attest that I am
authorized to execute this certification on behalf of the above-referenced person or entity.
Bidder:
Signature:
Print Name:
Title:
Date:
P-9
? 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF
BARNEGAT
Form W-9
lRev.August20l3)
Depanmen} ol lhe Tyeasury
Inteinal Revenue Service
r
Name (as ahown on your income }ax-re}um)
N
j;f
X[
'jl
. l Business name7aisreqatded en(Ity name, if d?lleieni krom'ab:ive
Nl
ffl i +5-l:n;i'v7d:l/'s-oa-lawprWp'-ri'e:'7a= aE]-a:;oa:oa';a'::on a - ,,p..=., a Parjnership a -,..-..,l.
i!Busn""name/d'egadedenl"am"Idllerenl
Clty, state, and ZIP code
Mdress (number, s}reel, and apl. or suile no.)
[] Olher (see insLruchonsl >
0 Limi}ed liability company. Emer the tax classijicatlon (C-C coyporaiion, 8-S cotpoyaiion, P=par(nership) k
Exemptions (see instruciions):
Exempt payee code lil any)
Exemp}ion from FATCA repoding
code {il any)
f
'trsi account number(s) here (opi:onai)
s Taxpayer Identification Number (T IN)
Enler your TIN m the appropriaje box The TIN provided mus} match the name given on the Name Iine 800181 80ckl(lbl num5er
aa -ag -m
10 aVoid backup withholding. For individuals, this :s your 80cial secUlity number (SSN). HoweVer. for a
resldem alien, sole pyoprietor, or disreqan:Ied en(ffly. see (he Pan l instructions on paqe 3. For o{hey
enti}ies, i! is your employer identiiication number (EIN). If you do not have a number. see How lo gel a
TIN on par;le 3.
Note. If the account is in more than one name, see the chark on page 4.loy guidelines on whose
iEmployer identi{ication number
number to enter.
Give Form to the
requesier. Do not
send to the IRS.
Request for Taxpayer
Identification Number and Certification
l==es""am0andad'essio"lona)
l
I
l
l
fl certif}cation
under penalties of perjury, l certify }hat:
1 . The number shown on }his form is my cotyect taxpayev iden}iiication number (or l am waiting jor a number to be issued to me), and
2. l am not subject (o backup withholding because: (a) I am exsmpt from backup withholding. or (b) I have not been no}ified by the Intsrnal Revenue
Service (lRSj tha} l am su61ect to backup wlthhokjing as a resu:t oj a failure to repork all inieresi or dividends. or (c) the IRS has no(ified me that I am
no Ionger sub%ct lo backup wIthholding, and
3. l am a u.s. cItizen or other u.s. person (defined below). and
4. The FATCA cods[s) entered on this form (if any) indlca}ing }hat l am exempt from FATCA reporting is correct.
Certlficatlon instructions. You must cyoss out item 2 above if you have been notified by the IRS tha} you are currently subiect to backup withholding
because you heive failed to report all in}erest and dividerids on your tax return. For real e'ita}e transactions, item 2 does not-apply. For mortgage
interest paid, acquisition or abandonment of secured property, cancellation ol debI contribu}ions lo an individual vetireman( arrangement (ICIA). and
generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the
instructions on paqe 3.
Sign
Here l
8ignature of
u.s. peraon k
General Instructions
Seckion yelerences ate ko (he ln(emal Revenue Code unless okherslse noked.
Future developments. The IRS has ctea{ed a paqe on lRS.gov lot imormation
about Foym W-9, al wwwlrs.govlw9. lnforma(ion ;iboul anyjukure developmenks
allec{lnq Fotm W-9 (such as legisla}ion enacted ajter we release R) will be pos}ed
on that page.
Purpose of Form
A person who is yequited lo lile an ir?lotma{iors return wIth }he IRS must ob(ain youy
coyyact {axpayey identijica}ion number [T IN) }o reporj. ior example. income paid to
you, paymen(s made to you in sel(lemen( of paymem card and (hird par{y nekwork
{lansac{iOn9. 1081 esmke Iransaclionsi morlgage inleresl 9011 paid. acquisiliOn 01
abandonmem ol secured pyopayty, cancellation ol deb}, or contributions you made
ko an IRA.
Use Foym W-9 only 11 you aye a u.s. psson llncluding a yesiden{ allen), to
pyovlde 4oul collecl TIN 10 lhe pelson requea}ing 11 (lha requester) and. when
applicable, lo:
S . Ceriily tha( the TIN you aye gMng is coyyoct {oy you ata waiilng (oy a number
to be issui).
2. Cer!lty }hai you are not sublect }o backuD wl}hholding. oy
3...Claim exemptIon lyom backup.wl}hholding if you aye a u.s. exempt payee. 11
applicable. you ayo also certl{yliig thai as a u.s. person, youy allocable share ol
any partnershIp income lyom a u.s. {tade oy business is no{ subiect to the
Ca(. No. I0231X
0aka k
wilhholdlng lax on loreign parlners' shale 01 e{fecliVely connecled Income. and
4. Ceyiily that FATCA codels) enlered on }his Ioym (ij any) indlca(ing tha} you ate
exempj lrom the FATCA repoffing, is coyyecl.
Note. 11 you are a u.s. peyson and a reques(er gives you a lorm o}her }han Form
W-9 to tequest your Tl?ll, you must use Ihe teieskey's lorm ?k it is subskam(ally
similar }o }his Form W-9.
Definition of a u.s. person. For lederal Iax purgoses. you aye oonsldered a u.s.
person il you are:
* An individual who Is a u.s. cnizen OI u.s. residen} alien,
* A par}nerghip, coipora}ion. com(>any, oy associa{ion creatad oy organized in the
Llnlied Sta}es'or under jhe Iaws or the Uni}ed Siates,
* An esia}e (other than a loteign esbkeJ, or
* A domestic {nisl las deiined in Regula}ions sction 301 .7701-7}.
Special rules lor partnershIps. Parknerships tha! cr>nduc} a lrade or business in
kt'le untied Siates aye generajly required }o pay a wi}hholding lax under section
1446 on any loreign parkneisa share oj elledivaly connected }axable Income lrom
such business. Fur}her. in certain casea where a Form W-9 has not been teceiverl,
the rules under section 1446 yequka a parinershlp (o pnasume khat a parhier is a
koyeklts person. and pay the section 1446 wi}hhoiding'tax. Theyelore. !l you are a
lJ.S. -person that is a par}nsi in a par}nership conduciliig a (rade ot bus!ness In }he
at is a par}nsi i
provIde Form 'W-9'io the paanershlp (o es}abllsh your u.s. $ta}us
Uni}ed States,
and avoid sed!on 1446 withholdiiig on your share 'ol par}ngshlp-Income.
Fom W19 lRev.-El-2013)
P-1 0
Nj????3.. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2€ll9
Fair and Open Contract Contribution Prohibition Language
Required pursuant to N.J.S.A. 1 9:44A-8 or 1 9:44A-16
rownship of Barnegat
Political Contribution Disclosure. This contract has beeri awarded to
based on the merits and abilities of
Contractor Name
Contractor Name
provide the goods or services as described herein. This contract was not awarded
through a "fair and open process" pursuant to N.J.S.A. 1 9:44A-20.4 et seq. As
such, the undersigned does hereby attest that
it's
Contractor Name
subsidiaries, assigns or principals controlling in excess of 10% of the company has
neither made a contribution, that is repoitable pursuant to the Election Law
Enforcement Commission pursuant to N.J.S.A. 19:44A-8 or 19:44A-16, in the one (1 )
year period preceding the award of the contract that would, pursuant to P.L. 2004,
c.19, affect its eligibility to perform this contract, nor will it make a reportable
contribution during the term of the contract to any political party committee in the
Township of Barnegat/Ocean County, if a member of that political party is serving in
an elective public office of that Township of Barnegat/Ocean County when the
contract is awarded, or to any candidate committee of any person serving in an
elective public office of that Township of Barnegat/Ocean County when the contract
is awarded.
P-1 1
??N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
BUSINESS ENTITY DISCLOSURE CERTIFICATION
FOR FAIR AND OPEN CONTRACTS
Required Pursuant To N.J.S.A. 19:44A-20.8
TOWNSHIP OF BARNEGA T
Part I- Vendor Affirmation
The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that the
<name of business entity> has not made and will not
make any reportable contributions pursuant to N.J.S.A. 19:44A-1 et seq. that, pursuant to P.L. 2004, c. 19
would bar the award of this contract in the one year period preceding
(date
of award scheduled for approval of the contract by the governing body) to any of the following named
candidate committee, joint candidates committee; or political party committee representing the elected
officials of the TOWNSHIP OF BARNEGAT as defined pursuant to N.J.S.A. 1 9:44A-3(p), (q) and (r).
r
l
l
l
l
l
r
l
l
r
l
l
l
l
l
Part ll- Ownership Disclosure Certification
€al certify that the Iist below contains the names and home addresses of all owners holding 1 0% or more
of the issued and outstanding stock of the undersigned.€
Check the box that represents the type of business entity:
€Partnership €Corporation €€SoleProprietorship €SubchapterSCorporation
€Limited Partnership €Limited Liability Corporation €Limited Liability Partnership
Part 3 - Signature and Attestation:
The undersigned is fully aware that if l have misrepresented in whole or part this affirmation and
certification, I and/or the business entity, will be liable for any penalty permitted under Iaw.
Name of Business Entity:
Signature of Affiant:
Name of Affiant:
Title
Date
P-1 2
Name of Stock or Shareholder
Home Address
Subscribed and sworn before me this day of
,2 .
(Witnessed or attested by)
My Commission expires:
(Seal)
?.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
BI ISINFSS ENTITY DISCLOSURE CERTIFICAT?ON
FOR FAIR AND OPEN CONTRACTS
Required Pursuant To N.J.S.A. 19:44A-20.8
TOWNSHIP OF BARNEGA T
The following is statutory text related to the terms and citations used in the Business Entity
Disclosure Certification form.
"Local Unit Pay-To-Play Law" (P.L. 2004, c.19, as amended by P.L. 2005, c.51)
19:44A-20.6 Certain contributions deemed as contributions by business entity.
s. When a business entity is a natural person, a contribution by that person's spouse or child, residing
therewith, shall be deemed to be a contribution by the business entity. When a business entity is other
than a natural person, a contribution by any person or other business entity having an interest therein shall
be deemed to be a contribution by the business entity.
19:44A-20.7 Definitions relative to certain campaign contributions.
6. As used in sections 2 through 12 of this act: "business entity" means any natural or Iegal person,
business corporation, professional services corporation, Iimited Iiability company, partnership, limited
partnership, business trust, association or any other Iegal commercial entity organized under the laws of
this State or of any other state or foreign jurisdiction: "interest" means the ownership or control of more
?han 10% of the prof!?s or assets of a business en}!}7 0r 10% of ?he s?ock in the case of a bus!ness entit7
that is a corporation for profit, as appropriate;
Temporary and Executing
12. Nothing contained in this act shall be construed as affecting the eligibility of any business entity to
perform a public contract because that entity made a contribution to any committee during the one-year
period immediately preceding the effective date of this act.
The New Jersey Campaign Contributions and Expenditures Reporting Act (N.J.S.A. 19:44A-1
et seq.)
19:44A-3 Definitions. In pertinent part...
p. The term "political party committee" means the State committee of a political party, as organized
pursuant to R.S.19:5-4, any county committee of a political party, as organized pursuant to R.S.19:5-3, or
any municipal committee of a political party, as organized pursuant to R.S.19:5-2.
q. The term "candidate committee" means a committee established pursuant to subsection a. of section 9
of P.L. 1973, c.83 (C. 1 9:44A-9) for the purpose of receiving contributions and making expenditures.
r. the term 'Ioint candidates committee" means a committee established pursuant to subsection a. of
section 9 of P.L.1973, c.83 (C.19:44A-9) by at Ieast two candidates for the same elective public offices in
the same election in a Iegislative district, county, municipality or school district, but not more candidates
than the total number of the same elective public offices to be filled in that election, for the purpose of
receiving contributions and making expenditures. For the purpose of this subsection: ...; the offices of
member of the board of chosen freeholders and county executive shall be deemed to be the same elective
public offices in a county; and the offices of mayor and member of the municipal governing body shall be
deemed to be the same elective public offices in a municipality.
19:44A-8 and 16 Contributions, expenditures, reports, requirements.
While the provisions of this section are too extensive to reprint here, the following is deemed to be the
pertinent part affecting amounts of contributions:
"The $300 limit established in this subsection shall remain as stated in this subsection without further
adjustment by the commission in the manner prescribed by section 22 of P.L. 1993, c.65 (C. 19:44A-7.2)
P-1 3
?N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
C. 271 POL?TICAL CONTRIBUTION DISCLOSURE FORM
Contractor Instructions
Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to a "fair and
open" process (defined at ?.. 19:44A-20.7) are subject to the provisions of P.L. 2005, c. 271, s.2 (?..
19:44A-20.26). This Iaw provides that 10 days prior to the award of such a contract, the contractor shall disclose
contributions to:
any State, county, or municipal committee of a political party
any Iegislative Ieadership committee"
any continuing political committee (a.k.a., political action committee)
any candidate committee of a candidate for, or holder of, an elective office:
o
of the public entity awarding the contract
o
of that county in which that public entity is Iocated
o
of another public entity within that county
o
or of a Iegislative district in which that public entity is Iocated or, when the public entity is
a county, of any Iegislative district which includes all or part of the county
The disclosure must Iist reportable contributions to any of the committees that exceed $300 per election cycle that
were made during the 12 months prior to award of the contract. See ?.. 19:44A-8 and 19:44A-16 for more
details on reportable contributions.
*
*
*
?.. 1 9:44A-20.26 itemizes the parties from whom contributions must be disclosed when a business entity is not
a natural person. This includes the following:
*
individuals with an "interest" ownership or control of more than 10% of the profits or assets of a business
entity or 1 0% of the stock in the case of a business entity that is a corporation for profit
all principals, partners, officers, or directors of the business entity or their spouses
any subsidiaries directly or indirectly controlled by the business entity
IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business
entity and filing as continuing political committees, (PACs).
When the business entity is a natural person, "a contribution by that person's spouse or child, residing therewith,
shall be deemed to be a contribution by the business entity." [?.. 19:44A-20.26(b)] The contributor must be
Iisted on the disclosure.
@
@
*
Any business entity that fails to comply with the disclosure provisions shall be subject to a fine imposed by ELEC in
an amount to be determined by the Commission which may be based upon the amount that the business entity failed
to report.
The enclosed Iist of agencies is provided to assist the contractor in identifying those public agencies whose elected
official and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor's
responsibility to identify the specific committees to which contributions may have been made and need to be
disclosed. The disclosed information may exceed the minimum requirement.
The enclosed form, a content-consistent facsimile, or an electronic data file containing the required details (along with
a signed cover sheet) may be used as the contractor's submission and is disclosable to the public under the Open
Public Records Act.
The contractor must also complete the attached Stockholder Disclosure Certification. This will assist the agency in
meeting its obligations under the Iaw. NOTE: This section does not apply to Board of Education contracts.
" ?.. 19:44A-3(s): "The term "legislative leadership committee" means a committee established, authorized to
be established, or designated by the President of the Senate, the Minority Leader of the Senate, the Speaker of the
General Assembly or the Minority Leader of the General Assembly pursuant to section 16 of P.L.1993, c.65
(C.1 9:44A-1 0.1 ) for the purpose of receiving contributions and making expenditures."
P-14
LLUA.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
C. 271 POLIT?CAL CONTRIBUT?ON DISCLOSURE FORM
Required Pursuant To N.J.S.A. 19:44A-20.26
TOWNSHIP OF BARNEGAT
Part l- Vendor Information
Qndor Name: i
l
The undersigned being authorized to certify, hereby certifies that the submission provided herein represents
compliance with the provisions of N.J.S.A. 1 9:44A-20.26 and as represented by the Instructions accompanying
this form.
Signature
Printed Name
Title
Part ll- Con'4-w:}
4:
mlllJlllllmlon Disclosure
€ Check here if disclosure is provided in electronic form.
g Check here if the information is continued on subsequent page(s)
P-15
This form or its permitted facsimile must be submitted to the Iocal unit
no later than 10 days prior to the award of the contract.
Address: i
City: i i State: i Zip:
Disclosure requirement: Pursuant to .. 19:44A-20.26 this disclosure must include all
reportable political contributions (more than $300 per election cycle) over the 12 months prior to
submission to the committees of the government entities listed on the form provided by the Iocal unit.
Contributor Name
Recipient Name
Date
Dollar Amount
$
N??.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
Continuation Page
C. 271 POLITICAL CONTR?BUTION DISCLOSURE FORM
Required Pursuant To N.J.S.A. 19:44A-20.26
TOWNSHIP OF BARNEGAT
Page of
Vendor Name:
g Check here if the information is continued on subsequent page(s)
P-1 6
Contributor Name
Recipient Name
Date
Dollar Amount
$
N??.. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
List of Agencies with Elected Officials Required for Political Contribution Disclosure
N.J.S.A. 19:44A-20.26
County Name: Ocean
State: Governor, and Legislative Leadership Committees
Legislative District #s: 9, 10, & 30
State Senator and two members of the General Assembly per district.
County:
Freeholders
County Clerk
Sheriff
Surrogate
Municipalities (Mayor and members of governing body, regardless of title):
Barnegat Light Borough
Barnegat Township
Bay Head Borough
Beach Hamn Borough
Beachwood Borough
Berkeley Township
Brick Township
Dover Township
Eagleswood Township
Harvey Cedars Borough
Island Heights Borough
Jackson Township
Lacey Township
Lakehurst Borough
Lakewood Township
Lavallette Borough
Little Egg Harbor Township
Long Beach Township
Manchester Township
Mantoloking Borough
Ocean Gate Borough
Ocean Township
Pine Beach Borough
Plumsted Township
Point Pleasant Beach Borough
Point Pleasant Borough
Seaside Heights Borough
Seaside Park Borough
Ship Bottom Borough
South Toms River Borough
Stafford Township
Surf City Borough
Tuckerton Borough
Boards of Education (Members of the Board):
Barnegat Township
Bay Head Borough
Beach Haven Borough
Berkeley Township
Brick Township
Central Regional
Eagleswood Township
Island Heights Borough
Jackson Township
Lacey Township
Lakehurst Borough
Lakewood Township
Lavallette Borough
Little Egg Harbor Township
Long Beach Island
Manchester Township
Mantoloking
Ocean Gate Borough
Ocean Township
Pinelands Regional
Plumsted Township
Point Pleasant Beach Borough
Point Pleasant Borough
Seaside Heights Borough
Seaside Park Borough
Southern Regional
Stafford Township
Toms River Regional
Tuckerton Borough
Fire Districts (Board of Fire Commissioners):
Brick Township Fire District No. 1
Brick Township Fire District No. 2
Brick Township Fire District No. 3
Dover Township Fire District No. 1
Dover Township Fire District No. 2
Jackson Township Fire District No. 1
Jackson Township Fire Distri6t No. 2
Jackson Township Fire District No. 3
Jackson Township Fire District No. 4
Lakewood Township Fire District No. 1
Little Egg Harbor Township. Fire District No. 1
Little Egg Harbor Township Fire District No. 2
Plumsted Township Fire District No. 1
P-1 7
N??.. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
STOCKHOLDER DISCLOSURE CERTIFICATION
This Statement Shall Be Included with Bid Submission
Legal Name of Bidder:
List the names and addresses of all stockholders who own ten (1 0%) percent or more of the above company's stock, and if
there are NO STOCKHOLDERS OF 10% OR MORE, simply check the second box below. If one or more such
stockholders or partner is itself a corporation or partnership, the stockholders holding 1 0% or more of that corporation's stock,
or the individual partners owning 1 0% of that corporation's stock, or the individual partners owning 1 0% or greater interest in
that partnership, as the case may be, must also be listed.
The disclosure shall be continued until names and addresses of every person who is a non-corporate stockholder,
or individual partner, exceeding the 10% ownership criteria established in this act, has been Iisted, in full
compliance with Chapter 33 of the New Jersey Public Laws of 1977.
Please check only one:
€ I certify that the list below contains the names and addresses of all stockholders holding 10%
or more of the issued and outstanding stock of the undersigned.
OR
a
l certify that no one stockholder owns 1 0% or more of the issued and outstanding stock of the
undersigned.
Publicly Traded - For publicly traded entities to comply with N.J.S.A. 52:25-24.2 they may submit the name and address of
each publicly traded entity, and the name and address of each person holding 1 0% or more beneficial interest in the publicly
traded entity as of the Iast the last annual filling with the Security Exchange Commission (SEC), or foreign equivalent
Submit here the Website (URL) providing the Iast annual Security Exchange Commission (SEC) filing, or foreign equivalent:
The requested information is available on the following page number(s) of the SEC, or foreign equivalent, filing:
Check the box that represents the type of business organization:
€Partnership
€Limited Partnership
€Limited Liability Partnership
€Corporation
€Limited Liability Company
€Subchapter S Corporation
€Sole Proprietorship
P-18
?N.J.S.A. 19:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
Sign and notarize the form below, and, if necessary, complete the stockholder Iist below.
Stockholders:
(Note: Attach additional pages if necessary)
Subscribed and sworn before me this day of
,2 .
(Notary Public)
My Commission expires:
(Affiant)
(Print name & title of affiant)
(Corporate Seal)
P-1 g
Stockholder Name:
Address:
Percentage of Ownership: %
Stockholder Name::
Address:
Percentage of Ownership: %
Stockholder Name::
Address:
Percentage of Ownership: %
Stockholder Name::
Address:
Percentage of Ownership: %
Stockholder Name:
Address:
Percentage of Ownership: %
Stockholder Name::
Address:
Percentage of Ownership: %
?N.J.S.A. 1 9:44A-20.4, et seq., - Barnegat Township -not to exceed $39,999.99 for Calendar Year 2019
TOWNSHIP OF BARNEGAT
Reporting to the Office of the State Comptroller
Office of the NJ State Comptroller (OSC): N.J.S.A. 52:15C-10 requires contracts
exceeding $2,000,000 but below $10,000,000 to be reported to the OSC within twenty
(20) days after award, and that proposed contracts exceeding $10,000,000 must be
approved by the OSC prior to awarding the contract. Contracts awarded under a
national cooperative agreement are subject to these requirements. In addition, the
OSC may audit or review contracts of any amount or type and may audit or review the
records of the vendor as well.
OSC has adopted a regulation, N.J.A.C. 1 7:44-2.2, which requires contracting units to
insert the following language into all contracts:
"The vendor shall maintain all documentation related to products, transactions or
services under this contract for a period of five (5) years from the date of final
payment. Such records shall be made available to the New Jersey Office of the State
Comptroller upon request."
Signed this
day of
(Bidder)
By
Signature of Authorized Individual,
Partner or Officer Signing the Proposal
Print Name:
Title:
Date:
P-20
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"...A contractor, subcontractor or supplier who fails to provide proof of business registration or provides false business registration information shall be liable to a penalty of $25 for each day of violation, not to exceed $50,000 for each business registration not properly provided or maintained under a contract with a contracting agency...."
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First Discovered
Apr 1, 2026
Last Info Update
Apr 1, 2026
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