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Executive Summary
This document comprises a mandatory set of compliance forms for vendors seeking to enter into Non-Fair and Open contracts with the Township of Barnegat, New Jersey. It requires comprehensive disclosures from business entities, including ownership details, political contributions made to local and state officials, and affirmations regarding investment activities in Iran in accordance with state law. Additionally, the forms include standard bidding requirements such as non-collusion affidavits, certifications of equal employment opportunity and affirmative action compliance, and acknowledgment of the Township's right to extend the contract award period.
Prospective bidders must complete and submit these forms as part of their bid package to ensure legal and ethical compliance for any contract awarded by the Township. Failure to provide complete and accurate information, particularly concerning investment activities in Iran, may result in the bid being deemed non-responsive and subject to penalties as prescribed by law.
These forms are foundational for establishing eligibility and demonstrating adherence to New Jersey's public contracting regulations for Barnegat Township projects.
Web Content
Automated discovery link found on Barnegat website.
Document Text
--- Document: Non Fair and Open contract forms Document ---
PLEASE EXECUTE THIS FORM AND SUBMIT WITH THE BID PACKAGE
BUSINESS ENTITY DISCLOSURE CERTIFICATION
FOR NON-FAIR AND OPEN CONTRACT (N.J.S.A. 19:44A-20-8)
NAME OF BUSINESS:
VENDOR AFFIRMATION: The undersigned, being authorized and knowledgeable of the
circumstances, does hereby certify that <Name of Business> 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 Barnegat Township) to any of the following named candidate committee, joint
committee; of political party committee representing the elected officials of the <name of entity of
elected officials> as defined pursuant to N.J.S.A. 19:44A-3(p), (q) and (r).
OWNERSHIP DISCLOSURE CERTIFICATION:
I certify that the list below contains the names and home addresses of all stockholders
holding 10% or more of the issued and outstanding stock of the undersigned.
Check the box that represents the type of business organization:
Partnership
Corporation
Sole Proprietorship
Limited Partnership
Subchapter S Corporation
Limited Liability Corporation
Limited Liability Partnership
Name of Stock or Stockholder
Home Address
SIGNATURE AND ATTESTATION:
The undersigned is fully aware that if I have misrepresented in whole or part of this
affirmation and certification, I and/or the business entity, will be liable for any penalty
permitted under law.
Name of Business Entity:
Signed:
Title:
Print Name:
Date:
Subscribed and sworn before me this
day
(Affiant)
of
20
(Print Name & Title)
My Commission expires:
(Corporate Seal)
1
CHAPTER 271 POLITICAL CONTRIBUTION DISCLOSURE FORM
Require Pursuant to N.J.S.A. 19:44A-20.26
This form or its permitted facsimile must be submitted to Barnegat Township
no later than 10 days prior to the award of the contract. Required in addition to the
Business Entity Disclosure Certification
Part I - Vendor Information
Vendor Name:
Address:
City:
State:
Zip:
The undersigned being authorized to certify, hereby certifies that the submission provided
herein represents compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented
by the Instructions accompanying this form.
Signature
Printed Name
Title
Part II - Contribution Disclosure
Disclosure requirement: Pursuant to N.J.S.A> 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
Barnegat Township.
Check here if disclosure is provided in electronic form.
Contributor Name
Recipient Name
Date $ Amount
Check here if the information is continued on subsequent pages(s).
Agencies with Elected Officials Required for Political Contribution Disclosure
County Name:
N.J.S.A. 19:44A-20.26
State: Governor and Legislative Leadership Committees
Legislative District #(s):
State Senator and two members of the General Assembly per district
County:
Freeholders
{County Executive}
County Clerk
Surrogate
Sheriff
Municipalities (Mayor and members of governing body, regardless of title)
2
THE TOWNSHIP OF BARNEGAT
900 WEST BAY AVENUE
BARNEGAT, NJ 08005
RIGHT TO EXTEND - TIME FOR AWARD
The Township of Barnegat is required by The Local Public Contracts Law, N.J.S.A. 40A:11-24,
to make an award on products or services within sixty (60) days of the bid opening date.
Should the Township of Barnegat require an additional thirty (30) days extension to make an
award of this bid, by signing this document you shall grant the Township of Barnegat the right
to extend this award up to ninety (90) days, if deemed necessary.
SIGNED:
TITLE:
COMPANY:
DATE:
(Signature)
(Print or Type)
TYPE OF PRODUCT OR SERVICE OFFERED:
3
PLEASE EXECUTE THIS FORM AND SUBMIT WITH THE BID PACKAGE
STOCKHOLDER DISCLOSURE STATEMENT
Name of Business:
I certify that the list below contains the names and home addresses of all stockholders
holding 10% or more of the issued and outstanding stock of the undersigned.
OR
I certify that no one stockholder owns 10% or more of the issued and outstanding stock
of the undersigned.
Check the box that represents the type of business organization:
Partnership
Corporation
Sole Proprietorship
Subchapter S Corporation
Limited Partnership
Limited Liability Corporation
Limited Liability Partnership
Sign and notarize the form below, and, if necessary, complete the stockholder list below.
STOCKHOLDERS:
Name:
Address:
Name:
Address:
Name:
Address:
Name:
Address:
Name:
Address:
Subscribed and sworn before me this
of
(Notary Public)
20
My Commission expires:
day
Name:
Address:
(Affiant)
(Print Name & Title)
(Corporate Seal)
4
PLEASE EXECUTE THIS FORM AND SUBMIT WITH THE BID PACKAGE
NON-COLLUSION AFFIDAVIT
STATE OF
COUNTY OF
1,
(Partnership, Corporation, Individual, LLC)
In the County of
of
and the State of
of full age, being duly sworn according to law on my oath depose and say that:
I am
of the firm of
the
bidder making the Proposal for the above named project, and that I executed the said Proposal
with full authority so to do; 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 connection with the above named project; and that all statements contained in
said Proposal and in this Affidavit are true and correct and made with full knowledge that the
State of New Jersey relies upon the truth of the statements contained in said Proposal 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 maintained by
(N.J.S.A. 52:34-15)
Signature of Contractor_
Subscribed and Sworn to
(Name of Contractor)
Before me this
(Signature)
(Please Print Name)
day of
20
Subscribed and sworn before me this
(Notary Public)
My Commission expires:
20
day of
5
PLEASE EXECUTE THIS FORM AND SUBMIT WITH THE BID PACKAGE
N.J.S.A. 10:5-31 and N.J.A.C. 17:27
MANDATORY EQUAL EMPLOYMENT OPPORTUNITY LANGUAGE
Goods, Professional Services and General Service Contracts
(Mandatory Affirmative Action Language)
During the performance of this contract, the Contractor agrees as follows:
The Contractor or Sub-Contractor, 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 take affirmative action to ensure that such applicants
are recruited and employed, 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 action shall
include, but not 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 Sub-Contractor, 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 Sub-Contractor, where applicable, will send to
each labor union or representative or workers with which it has a collective bargaining
agreement or other contract or understanding, a notice, to be provided by the agency
contracting officer advising the labor union or workers' representative of the Contractor's
commitments under this act and shall post copies of the notice in conspicuous places available
to employees and applicants for employment.
The Contractor or Sub-Contractor 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 Sub-Contractor agrees to make good faith efforts to employ minority and
women workers consistent with the applicable county employment goals established in
accordance with N.J.A.C. 17:27-5.2, or a binding determination of the applicable county
employment goals determined by the Division, pursuant to N.J.A.C. 17:27-5.2.
The Contractor or Sub-Contractor agrees to inform in writing its appropriate recruitment
agencies including, but not limited to, employment agencies, placement bureaus, colleges,
universities, labor unions, that it does not discriminate on the basis of age, 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.
6
The Contractor or Sub-Contractor agrees to revise any of its testing procedures, if necessary,
to assure that all personal testing conforms to 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 applicable employment goals, the Contractor or Sub-Contractor agrees
to review all procedures relating to transfer, upgrading, downgrading and layoff to ensure that
all such actions are taken without regard to age, 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.
N.J.S.A. 10:5-31 and N.J.A.C. 17:27
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
The Contractor and its Sub-Contractor shall furnish such reports or other documents to the
Division of Contract Compliance & EEO as may be requested by the Division 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 Contract Compliance & EEO for conducting
a compliance investigation pursuant to Subchapter 10 of the Administrative Code at
N.J.A.C.17:27.
Submitted by:
(Name of Firm)
Name:
Signature:
Title:
(Please Type or Print)
Date:
7
PLEASE EXECUTE THIS REQUIRED FORM AND SUBMIT WITH BID PACKAGE
NOTICE TO BIDDERS
Re:
Affirmative Action Regulations P. L. 1975, С. 127
Procurement and Service Contractors
"Affirmative Action" rules N.J.A.C. 17:27-1 et seq.
"Bidders are required to comply with the requirements of N.J.S.A. 10:5-31 et seq. and
N.J.A.C. 17:27".
CONTRACTORS/VENDORS
A.
1.
B.
Contractors and/or vendors will submit with the signed proposal Affirmative
Action evidence. The affirmative Action evidence shall be in one of the following
forms.
a. An existing federally approved or sanctioned affirmative action program.
b.
c.
A Certificate of Employee Information Report from the Treasurer Office of
the State of New Jersey.
If the Contractor/Vendor cannot present "a" or "b" - the Contractor/Vendor
is required to submit a completed Employee Information Report (Form AA-
302). This form will be made available to Contractor/Vendor by the
Township of Barnegat within seven (7) days after notification of intent to
award the contract or receipt of the contract, whichever is sooner.
THE FOLLOWING QUESTIONS MUST BE ANSWERED BY ALL PROSPECTIVE
BIDDERS:
1.
Do you have a Federally approved or sanctioned Affirmative Action Program?
YES
NO
NO
2.
Do you have a State Certificate of Employee Information Report Approval?
YES
a.
If yes, please submit a photocopy of such Certificate of Employee
Information Report with this proposal.
The undersigned Contractor certifies that he/she is aware of the commitment to comply with
the requirements of P.L. 1975, C. 127, N.J.S.A. 10:5-31 et seq. and N.J.A.C. 17:27-1 et seq.
and agrees to furnish the required documentation pursuant to the law.
CONTRACTOR/VENDOR:
NOTE:
(Signature)
(Title)
A Contractor's bid shall be rejected as non-responsive, if a Contractor fails
to comply with the above requirements.
8
THE TOWNSHIP OF BARNEGAT
900 WEST BAY AVENUE
BARNEGAT, NJ 08005
ACKNOWLEDGEMENT OF RECEIPT OF ADDENDA
The undersigned Bidder does hereby acknowledge the receipt of the following Addenda issued
by the Township of Barnegat:
Addendum Number
Dated
Acknowledgement Receipt (initial)
Addenda were received:
Acknowledgement for:
(Name of Bidder)
By:
(Signature of Authorized Representative)
Name:
Title:
Date:
(Print or Type)
9
THE TOWNSHIP OF BARNEGAT
900 WEST BAY AVENUE
BARNEGAT, NJ 08005
BIDDER'S CHECKLIST
The following checklist is provided for each bidder to check off documents submitted with their
bid:
Bid Deposit in the form of a Certified Check, Cashier's Check,
Treasurer's Check or Bid Bond
Certificate from a Surety Company stating if the bid is accepted,
they will provide the required Performance Bond
Stockholders Disclosure Statement properly notarized listing stockholders
or partners owning ten percent (10%) or more of corporation or
partnership stock. (Required)
Political Contribution Disclosure Form
Business Entity Disclosure Certification (For Non-Fair & Open Contracts)
Non-Collusion Affidavit properly notarized (Required)
New Jersey Business Registration Certificate (BRC) (Required)
Affirmative Action Evidence (Required)
W-9 Form
Deviations from specifications, if applicable
Acknowledgement of Receipt of Addenda
Authorized signatures on all forms
10
THE TOWNSHIP OF BARNEGAT
900 WEST BAY AVENUE
BARNEGAT, NJ 08005
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN
PART 1: CERTIFICATION
BIDDERS MUST COMPLETE PART 1 BY CHECKING EITHER BOX.
FAILURE TO CHECK ONE OF THE BOXES WILL RENDER THE PROPOSAL NON-
RESPONSIVE.
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 list as a
person or entity engaging in investment activities in Iran. The Chapter 25 list 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 list
prior to completing the below certification. Failure to complete the certification will 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 local 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 5 of P.L.2012, c.25 (C52:32-59). 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:
OR
I certify, pursuant to Public Law 2012, c.25 that neither the bidder listed above nor any
of the bidder's parents, subsidiaries, or affiliates is listed on the New Jersey Department
of the Treasury's list of entities determined to be engaged in prohibited activities in Iran
pursuant to P.L.2012, с.25 ("Chapter 25 List"). I further certify that I am the person listed
above, or I am an officer or representative of the entity listed above and am authorized
to make this certification on its behalf. I will skip to Part 2 and sign and complete the
Certification below.
I am unable to certify as above because the bidder and/or one or more of its parents,
subsidiaries, or affiliates is listed on the Department's Chapter 25 list. 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 non-responsive and appropriate penalties, fines and/or sanctions will be
assessed as provided by law.
11
PART 2: PLEASE PROVIDE FURTHER INFORMATION REALTED TO INVESTMENT
ACTIVITIES 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 following information:
PROVIDE INFORMATION RELATIVE TO THE ABOVE QUESTIONS. PLEASE PROVIDE
THOROUGH ANSWERS TO EACH QUESTION. IF YOU NEED TO MAKE ADDITIONAL
ENTRIES, ATTACH ADDITIONAL PAGES.
Name:
Description of Activities:
Duration of Engagement:
Anticipated Cessation Date:
Relationship to Bidder/Offeror:
Bidder/Offeror Contact Name:
Contact #:
12
THE TOWNSHIP OF BARNEGAT
900 WEST BAY AVENUE
BARNEGAT, NJ 08005
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN
CERTIFICATION:
1,
being duly sworn upon my oath, hereby represent and state
that the foregoing information and any attachments thereto to the best of 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 I 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. I acknowledge that I am aware that it is a criminal offense to
make a false statement or misrepresentation in this certificate, and if I do so I recognize that I
am subject to criminal prosecution under the law and that it will also constitute a material
breach of my agreements(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.
I, being duly sworn upon my oath, hereby represent and state that the foregoing information
and any attachments thereto to the best of knowledge are true and complete. I attest that I am
authorized to execute this certification on behalf of the above-referenced person or entity.
Bidder:
Date:
(Signature)
(Print Name)
(Title)
13
ENTITIES DETERMINED TO BE ENGAGED IN PROHIBITED ACTIVITIES IN IRAN
PURSUANT TO P.L. 2012, С.25 (“CHAPTER 25")
LIST DATED AS OF FEBRUARY 5, 2016
1.
Bank of Markazi Iran (Central Bank of Iran)
2.
Bank Mellat
3.
Bank Melli Iran
4.
Bank Tejarat
5.
National Iranian Tanker Company (NITC)
6.
Amona
7.
Bank Saderat PLC
8.
Bank Sepah
9.
Belaz
10.
Belneftkhim (Belarusneft)
11.
12.
China International United Petroleum & Chemicals Co., Ltd. (Unipec)
China National Offshore Oil Corporation (CNOOC)
13. China National Petroleum Corporation (CNPC)
14.
China National United Oil Corporation (ChinaOil)
15. China Petroleum & Chemical Corporation (Sinopec)
16.
China Precision Machinery Import-Export Corporation (CPMIEC)
17.
18.
19.
20.
Grimley Smith Associates
Indian Oil Corporation
Kingdream PLC
Maire Tecnimont SpA
21.
Naftiran Intratrade Company (NICO)
22.
Oil and Natural Gas Corporation (ONGC)
23.
Oil India Limited
24.
Persia International Bank
25.
PetroChina Company, Ltd.
26.
Petroleos de Venezuela (PDVSA Petróleo, SA)
27.
Sameh Afzar Tajak Co. (SATCO)
28.
Shandong FIN CNC Machine Company, Ltd.
29.
Sinohydro
30.
SK Energy
31.
SKS Ventures
32.
Som Petrol AS
33.
Zhuhai Zhenrong Company
14
AGENCIES IN OCEAN COUNTY NEW JERSEY WITH ELECTED OFFICIALS
REQUIRED FOR POLITICAL CONTRIBUTION DISCLOSURE
N.J.S.A. 19:44A-20.26
COUNTY NAME: OCEAN COUNTY
STATE: Governor and Legislative Leadership Committee
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 the governing body, regardless of title):
Barnegat Light Borough
Jackson Township
Lacey Township
Lakehurst Borough
Lakewood Township
Lavallette Borough
Barnegat Township
Bay Head Borough
Beach Haven Borough
Beachwood Borough
Berkeley Township
Brick Township
Dover Township
Eagleswood Township
Harvey Cedars Borough
Island Heights Borough
Little Egg Harbor Township
Long Beach Island Township
Manchester Township
Mantoloking Borough
Ocean Gate Borough
Ocean Township
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 Township
Manchester Township
Mantoloking Borough
Ocean Gate Borough
Ocean Township
Pinelands Regional
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 District No. 2
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
Plumsted Township
Point Pleasant Beach Borough
Point Pleasant Borough
Seaside Heights Borough
Seaside Park Borough
Southern Regional
Stafford Township
Toms River Regional
Tuckerton Borough
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
Little Egg Harbor Township Fire District No. 3
Plumsted Township Fire District No. 1
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performance bond
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Timeline
First Discovered
Apr 27, 2026
Last Info Update
May 23, 2026
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