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RFQ - Employee Assistance Program
BID #: 27
ISSUED: 10/14/2025
DUE: 11/14/2025
VALUE: $27,000,000
100
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Executive Summary
The Borough of New Providence is seeking Qualification Statements from interested parties for the provision of Employee Assistance Program (EAP) services for the calendar year 2026. The selected firm will provide services such as employee counseling, a 24-hour telephone hotline, and management training. Qualification Statements must include a description of the respondent's experience, understanding of the Borough's needs, and a cost proposal, among other requirements.
Interested respondents must submit their Qualification Statements to the Office of the Borough Clerk by November 14, 2025, at 11:00 AM. Submissions should include one original and one copy, along with a PDF version emailed to Clerk@newprov.us. UNLOCK Respondents must also complete and submit various forms, including a Non-Collusion Affidavit, Owner Disclosure Statement, and Business Registration Certificate.
Web Content
Bid Postings • RFQ - Employee Assistance Program Skip to Main Content Create a Website Account - Manage notification subscriptions, save form progress and more. Website Sign In Government Services Community How Do I... Search Home Bid Postings Print Sign up to receive a text message or email when new bids are added! Print Bid Title: RFQ - Employee Assistance Program Category: Request for Qualifications Status: Closed Description: The BOROUGH OF NEW PROVIDENCE (the "BOROUGH") is soliciting Qualification Statements from interested persons and/or firms for the provision of Employee Assistance services for calendar year 2026, as more particularly described herein. Publication Date/Time: 10/14/2025 12:00 AM Closing Date/Time: 11/14/2025 11:00 AM Related Documents: Employee Assistance Services 2026-2028 Return To Main Bid Postings Page Live Edit Forms & Documents Garbage / Recycling Online Business & Payments Community Activities Contact Us Notify Me® Public Notices Facebook Instagram Contact Us 360 Elkwood Avenue New Providence, NJ 07974 Phone: 908-665-1400 Fax: 908-665-9272 Regular Hours: Monday through Friday 8:30 AM to 4:30 PM Summer Hours: Friday before Memorial Day - Labor Day Monday through Thursday 8:30 AM - 4:30 PM Friday 8:30 AM - 1:00 PM Quick Links Smart 911 Links & Resources Property Information FAQs Calendar Film Ready /QuickLinks.aspx Helpful Links Home Site Map Contact Us (Directory) Accessibility Disclaimer Terms of Use & Privacy Policy /QuickLinks.aspx Government Websites by CivicPlus® Loading Loading Do Not Show Again Close Arrow Left Arrow Right [] Slideshow Left Arrow Slideshow Right Arrow
Document Text
--- Document: Employee Assistance Services 2026-2028 ---
BOROUGH OF NEW PROVIDENCE
REQUEST FOR QUALIFICATIONS
FOR EMPLOYEE ASSISTANCE PROGRAM
BOROUGH OF NEW PROVIDENCE
ISSUE DATE: October 14, 2025
SUBMISSION DEADLINE: November 14, 2025
ADDRESS ALL QUALIFICATION STATEMENTS TO:
OFFICE OF THE BOROUGH CLERK
Municipal Building
360 Elkwood Avenue
NEW PROVIDENCE, NEW JERSEY 07974
2
GENERAL INFORMATION & SUMMARY
ORGANIZATION REQUESTING QUALIFICATIONS
BOROUGH OF NEW PROVIDENCE
360 ELKWOOD AVENUE
NEW PROVIDENCE, NEW JERSEY 07974
CONTACT PERSON
BERNADETTE CUCCARO, ADMINISTRATOR
908-665-1400
PURPOSE OF REQUEST
The BOROUGH OF NEW PROVIDENCE (the "BOROUGH") is soliciting Qualification
Statements from interested persons and/or firms for the provision of Employee Assistance
services for calendar year 2026, as more particularly described herein. Through a Request for
Qualification process described herein, persons and/or firms interested in assisting the
BOROUGH with the provision of such services must prepare and submit a Qualification
Statement in accordance with the procedure and schedule in this RFQ. The BOROUGH will
review Qualification Statements only from those persons and/or firms that submit a Qualification
Statement which includes all the information required to be included as described herein, as
determined in the sole and absolute discretion of the BOROUGH. The BOROUGH intends to
qualify persons and/or firms that (a) possess the professional, financial and administrative
capabilities to provide the proposed services, and (b) will agree to work under the compensation
terms and conditions determined by the BOROUGH to provide the greatest benefit to the
taxpayers of New Providence. The services of successful Respondents may be procured as soon
as January 1, 2026.
DEFINED TERMS
The following definitions shall apply to and are used in this Request for Qualifications:
"BOROUGH" - refers to the BOROUGH OF NEW PROVIDENCE.
"Qualification Statement" - refers to the complete responses to this RFQ submitted by the
Respondents.
"Qualified Respondent" - refers to a Respondent who (in the sole and absolute discretion of
the BOROUGH) has satisfied the qualification criteria set forth in this RFQ.
"RFQ" - refers to this Request for Qualifications, including any amendments thereof or
supplements thereto.
"Respondent" or "Respondents" - refers to the interested persons and/or firm(s) that submit a
Qualification Statement.
CONTRACT FORM
3
If selected, a respondent shall be required to execute the BOROUGH’S form contract,
which includes, among other things, indemnification, insurance, termination and licensing
provisions. A complete copy of a draft BOROUGH form contract is available upon request.
It is also agreed and understood that the acceptance of the final payment by a vendor shall
be considered a release in full of all claims against the BOROUGH arising out of, or by reason
of, the work done and materials furnished under the contract.
REQUIREMENTS OF THE QUALIFICATION STATEMENTS
FOR LEGAL AND OTHER PROFESSIONAL SERVICES
1.
BOROUGH OF NEW PROVIDENCE FACTS AND FIGURES – The BOROUGH
OF NEW PROVIDENCE is a legal, governmental entity. The BOROUGH was incorporated in
1899 and operates under N.J.S.A 40A:60-1, et seq., the borough form of government. The
BOROUGH is governed by a mayor and borough council. The Borough Council sets policy,
adopt the operating and capital budgets for the BOROUGH, enacts ordinances and sets the
direction of how the BOROUGH OF NEW PROVIDENCE will provide government services.
The Mayor is elected and is the chief executive. The Borough Administrator carries out the
policies adopted by the Mayor and Borough Council.
The BOROUGH's population is approximately 13,650 and it consists of approximately
4 square miles of area. The BOROUGH provides a full range of municipal services.
The BOROUGH's operating budget is approximately $27,000,000.
The BOROUGH has approximately 65 full-time employees and approximately 100
volunteers and part-time employees.
2.
NATURE/ SCOPE OF SERVICES – The BOROUGH hereby solicits Qualification
Statements from Respondents that have expertise in providing employee assistance services,
including without limitation employee counseling, 24-telephone hotline, management training
and employee assistance. Respondents must demonstrate that they satisfy all professional
requirements and will have the continuing capabilities to perform these services.
3.
SUBMISSION REQUIREMENTS – Respondents must have a minimum of five (5)
years of experience in the practice of employee assistance. Each Qualification Statement must
clearly indicate the position(s) sought. Respondents should submit a Qualification Statement that
contains the following:
A.
The name of the Respondent, the principal place of business, and, if different, the
place where the services will be provided;
B.
A description of Respondent's overall experience in providing the type of services
sought in the RFQ At a minimum, the following information on past experience
should be included as appropriate to the RFQ: (i) description and scope of work
by Respondent; (ii) explanation of perceived relevance of the experience to the
RFQ; and (iii) the education, qualifications, experience, and training of all
persons who would be assigned to provide services along with their names and
titles;
4
C.
A narrative statement of the Respondent's understanding of the BOROUGH's
needs and goals;
D.
A narrative statement describing the Respondent’s understanding of the employee
assistance issues impacting New Jersey employers;
E.
A listing of all other engagements where services of the types being proposed
were provided in the past five (5) years. This should include other municipal
governments and other levels of government. Contact information for the
recipients of similar services must be provided. The BOROUGH may obtain
references from any of the parties listed;
.
A listing of all immediate relatives of the principal(s) of Respondent who are
BOROUGH employees or elected officials of the BOROUGH. For purposes of
the above, "immediate relative" means a spouse, parent, stepparent, brother, sister,
child, stepchild, direct-line aunt or uncle, grandparent, grandchild, and in-laws;
• A statement that neither the firm nor any individuals assigned to this
engagement are suspended, or otherwise prohibited from professional practice
by any federal, state, or local agency;
• An Affirmative Action Statement (sample language attached);
• A completed Non-Collusion Affidavit (copy of form attached);
• A completed Owner Disclosure Information form (copy of form attached);
• A statement that the Respondent will comply with the General Terms and
Conditions required by the BOROUGH and enter into the BOROUGH's
standard Professional Services Contract;
• A copy of the Respondent's Business Registration Certification; and
• A completed Disclosure Statement (copy of form attached).
4.
COST PROPOSAL – Respondents should submit a cost proposal that would include
any proposed retainer, the services to be provided for the retainer, if services will be provided at
a flat rate, if all or any services will be billed through hourly rates and what are the established
rate(s). Further, the proposal shall include commission arrangements with the various companies
the respondent conducts business with. The BOROUGH does not provide payment for
reimbursement for travel expenses.
5.
EVALUATION – The BOROUGH has structured a procurement process that seeks to
obtain the desired results described herein, while establishing a competitive process to assure that
each person and/or firm is provided an equal opportunity to submit a Qualification Statement in
response to the RFQ. The BOROUGH will select the most advantageous proposal(s), if any, and
as determined in its sole and absolute discretion, based on all of the evaluation factors set forth at
the end of this RFQ. The BOROUGH will make the award(s), if any, that is in the best interest of
the BOROUGH.
Qualification Statements will be reviewed and evaluated by the BOROUGH and its legal
and/or financial advisors (collectively, the "Review Team"). The Qualification Statements will
be reviewed to determine if the Respondent has met the minimum professional, administrative,
5
and financial areas and other requirements described in this RFQ. Each Respondent must satisfy
the objectives and requirements detailed in this RFQ. The successful Respondent shall be
determined by an evaluation of the total content of the Qualification Statement submitted. Under
no circumstances will a member of the Review Team review responses to an RFQ for an
appointment for which they or their firm submitted a response. Based upon the totality of the
information contained in the Qualification Statement, including information about the reputation
and experience of each Respondent, the BOROUGH will (in its sole and absolute discretion)
determine which Respondents are qualified from a professional, administrative and financial
perspective. Each Respondent that meets the requirements of the RFQ (determined in the sole
and absolute discretion of the BOROUGH) will be designated as a Qualified Respondent and
may then be given an opportunity to provide services to the BOROUGH.
The RFQ process commences with the issuance of this RFQ. It is anticipated that certain
Qualified Respondents will be selected to begin providing services to the BOROUGH as soon as
January 1, 2026. There can be no assurance, however, that any Qualified Respondent will be
selected.
All communications concerning this RFQ or the RFQ process shall be directed, in writing,
to the BOROUGH's designated contact person:
Bernadette Cuccaro, Borough Administrator
BOROUGH OF NEW PROVIDENCE
360 Elkwood Avenue, New Providence, New Jersey 07974
6.
RESERVATION OF RIGHTS – The BOROUGH reserves the right to:
a.
Not select any of the proposals;
b.
Select only portions of a particular Respondent's proposal for further
consideration (however, Respondents may specify portions of a proposal that they
consider "bundled");
c.
To supplement, amend or otherwise modify the RFQ through issuance of addenda
to all prospective Respondents who have received a copy of this RFQ;
d.
To change or alter the schedule for any events called for in this RFQ upon the
issuance of notice to all prospective Respondents who have received a copy of
this RFQ;
e.
To conduct investigations of any or all of the Respondents, as the BOROUGH
deems necessary or convenient, to clarify the information provided as part of the
Qualification Statement and to request additional information to support the
information included in any Qualification Statement; and
f.
To suspend or terminate the procurement process described in this RFQ at any
time (in its sole and absolute discretion). If terminated, the BOROUGH may
determine to commence a new procurement process or exercise any other rights
provided under applicable law without any obligation to the Respondents.
6
The BOROUGH shall be under no obligation to complete all or any portion of the
procurement process described in this RFQ.
The BOROUGH shall not be obligated to explain the results of the evaluation process to
any person or entity, including, without limitation, any Respondent.
The BOROUGH may require Respondents to demonstrate any services described in their
proposal prior to award.
7.
LIMITATIONS – This RFQ is not an offer, order or contract and should not be
regarded as such, nor shall any obligation or liability be imposed on the BOROUGH by issuance
of this RFQ. The BOROUGH reserves the right at the BOROUGH's sole discretion to refuse any
submission. This RFQ does not constitute a Request for Proposal ("RFP") and does not commit
the BOROUGH to issue an RFP.
8.
USE OF INFORMATION – Any specifications, drawings, sketches, models, samples,
data, computer programs, documentation, technical or business information and the like
("Information") furnished or disclosed by the BOROUGH to the respondent in connection with
this RFQ shall remain the property of the BOROUGH. When in tangible form, all copies of such
Information shall be returned to the BOROUGH upon request. Unless such Information was
previously known to the respondent, free of any obligation to keep it confidential, or has been or
is subsequently made public by the BOROUGH or a third party, it shall be held in confidence by
the respondent, shall be used only for the purposes of this RFQ, and may not be used for other
purposes except upon such terms and conditions as may be mutually agreed upon in writing.
9.
GENERAL TERMS AND CONDITIONS –
A.
The BOROUGH reserves the right to reject any Qualification Statement in whole
or in part or to waive any informalities in a Qualification Statement, and, unless
otherwise specified by the respondent, to accept any item, items or services in the
proposals should it be deemed in the best interest of the BOROUGH to do so.
B.
In case of the failure by a successful respondent to perform, the BOROUGH may
procure the articles or services from other sources, deduct the cost of the
replacement from money due to the respondent under the contract and hold the
respondent responsible for any excess cost occasioned thereby.
C.
The respondent shall maintain sufficient insurance to protect against all claims
under Workmen's Compensation, General, Professional and Automobile Liability.
D.
Each Qualification Statement must be signed by the person authorized to do so.
E.
An original and one copy of the Qualification Statements shall be hand-delivered
or mailed consistent with the provisions of the legal notice to respondents. In
addition, a Portable Document Format (PDF) of the Qualification Statement shall
be emailed to Clerk@newprov.us. In the case of mailed proposals, the
BOROUGH assumes no responsibility for Qualification Statements received after
the designated date and time. Late Qualification Statements will be returned
unopened. Proposals will not be accepted by facsimile. Proposals shall be in a
7
sealed envelope, marked "Qualification Statement for the Provision of Legal and
Other Professional Services." To be considered, proposals shall be delivered to or
received by the BOROUGH Clerk no later than 11 a.m. on November 14, 2025.
F.
Respondents are required to comply with the requirements of N.J.S.A. 10:5-31 et
seq. See attached Exhibit A.
G.
By submission of a Qualification Statement, the respondent certifies that the
service to be furnished will not infringe upon any valid patent, trademark or
copyright and a successful respondent shall, at its expense, defend any and all
actions or suits charging such infringement, and will save the BOROUGH
harmless in any case of any such infringement.
H.
No respondent shall influence, or attempt to influence, or cause to be influenced,
any BOROUGH officer or employee to use his/her official capacity in any
manner which might tend to impair the objectivity or independence of judgment
of said officer or employee.
I.
No respondent shall cause or influence, or attempt to cause or influence, any
BOROUGH officer or employee to use his/her official capacity to secure
unwarranted privileges or advantages for the respondent or any other person.
J.
Should any difference arise between the contracting parties as to the meaning or
intent of these instructions or specifications, the Borough Counsel's decision shall
be final and conclusive.
K.
All costs incurred by the Respondent in connection with responding to this RFQ
shall be become solely by the Respondent. The BOROUGH OF NEW
PROVIDENCE shall not be responsible for any expenditure of monies or other
expenses incurred by the Respondent.
L.
The checklist, affidavits, notices and the like presented at the end of this RFQ are
a part of this RFQ and shall be completed and submitted as part of a Qualification
Statement.
M.
All Qualification Statements shall become the property of the BOROUGH and
will not be returned.
N.
All Qualification Statements will be made available to the public at the
appropriate time, as determined by the BOROUGH (in the exercise of its sole and
absolute discretion) and in accordance with law.
O.
The BOROUGH may request Respondents to send representatives to the
BOROUGH for interviews with less than 24 hours' advance notice.
P.
Neither the BOROUGH, nor their respective staffs, consultants or advisors
(including, but not limited to, the Review Team) shall be liable for any claims or
damages resulting from the solicitation or preparation of the Qualification
Statement, nor will there be any reimbursement to Respondents for the cost of
8
preparing and submitting a Qualification Statement or for participating in this
procurement process.
Q.
If awarded a contract, your company/firm shall be required to comply with the
requirements of N.J.S.A. 10:5- 31 et seq. and N.J.A.C. 17:27
END OF GENERAL INSTRUCTIONS
9
BASIS OF AWARD
A contract, if any, shall be awarded based upon the following factors:
EVALUATION FACTORS
A.
Relevance and Extent of Qualifications, Experience, Reputation and Training of
Personnel to be assigned
B.
Knowledge of the BOROUGH OF NEW PROVIDENCE and the subject matter
to be addressed under this engagement
C.
Relevance and Extent of Similar Engagements performed
D.
Qualification Statement contains all required information
E.
Reasonableness of Cost Proposal
10
QUALIFICATION STATEMENT CHECKLIST
THIS CHECKLIST MUST BE COMPLETED, INITIALED, SIGNED AND SUBMITTED
WITH YOUR PROPOSAL. A PROPOSAL SUBMITTED WITHOUT THE
FOLLOWING DOCUMENTS IS CAUSE FOR REFUSAL.
INITIAL BELOW
A.
An original and one copy of the Qualification Statements
_________
B. Emailed Qualification Statements in a Portable
Document Format (pdf.) _________
C.
Non-Collusion Affidavit properly notarized
_________
D.
Owners Disclosure Statement, properly notarized, listing
the names of all persons owning ten (10%) percent or more
of the proposing entity
_________
E.
Authorized signatures on all forms
_________
F.
Business Registration Certificate(s)
_________
G.
Disclosure Statement
_________
H.
Affirmative Action Statement
_________
I.
Russia-Belarus and Iran Form
_________
J.
Political Contribution Disclosure
_________
Note: N.J.S.A 52:32-44 provides that the BOROUGH shall not enter into a contract for goods or
services unless the other party to the contract provides a copy of its business registration
certificate and the business registration certificate of any subcontractors at the time that it
submits its proposal. The contracting party must also collect the state use tax where applicable.
THE UNDERSIGNED HEREBY ACKNOWLEDGES
THE ABOVE LISTED REQUIREMENTS
NAME OF RESPONDENT:
___________________________________________________________________________________
Person, Firm or Corporation
___________________________________________________________________________________
BY: (NAME)
(TITLE)
11
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 af-forded
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 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 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. l7:27‑5.2.
12
EXHIBIT A (Cont)
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.
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 with 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.
13
NON-COLLUSION AFFIDAVIT
STATE OF NEW JERSEY )
) ss:
COUNTY OF __________ )
I, ______________________ of the City of _______________________ in the County of
____________________ and the State of ______________________ of full age, being duly
sworn according to the law on my oath depose and say that:
I am ________________________ of the firm of __________________________, the
respondent submitting the Qualification Statement, and that I executed the said Qualification
Statement with full authority so to do; and that said respondent 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 Qualification Statement; and that all
statements contained in said Qualification Statement 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 Qualification Statement and in the statements contained in this Affidavit in
awarding any contract for the named services.
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)
________________________________________
(Also type or print name of Affiant under signature)
Subscribed and sworn to before me this ____
day of _______________, 20__.
___________________________________
A Notary Public of ______________
My Commission Expires: ________________
14
OWNER DISCLOSURE INFORMATION
Set forth below are the names and addresses of all owners of 10% or more of the proposing
business entity.
Name: ____________________________
Name: ____________________________
Address: __________________________
Address: __________________________
__________________________
__________________________
Name: ____________________________
Name: ____________________________
Address: __________________________
Address: __________________________
__________________________
__________________________
Name: ____________________________
Name: ____________________________
Address: __________________________
Address: __________________________
__________________________
__________________________
Name: ____________________________
Name: ____________________________
Address: __________________________
Address: __________________________
__________________________
__________________________
___________________________
NAME OF BUSINESS ENTITY
__________________________________________________________________________
SIGNATURE
TITLE
_________________________________
Notary Public of
My Commission Expires: _____________, 20___.
15
DISCLOSURE STATEMENT
(To be submitted with Qualification Statement)
(a)
Is or was anyone in your firm or company a member of the BOROUGH governing body within the last calendar
year or a member of his/her immediate family? If yes, then provide the name of the individual below and his/her
relationship.
Yes____
No____
_______________________
__________________
________________
Name
Position
Relationship
(b)
Has any principal/partner of your firm been convicted of an indictable offense? If yes, then please provide further
explanation and copies of any relative documents.
Yes____
No____
_______________________
__________________
________________
Name
Position
Relationship
(c)
Has any individual who would provide service under this contract ever been sanctioned by the appropriate licensing
board?
Yes____
No____
_______________________
__________________
________________
Name
Position
Term
Reason for censure:
(d)
Has the firm been found liable for professional malpractice in the last 5 years?
Yes____
No____
Reason for Action:
(e)
Has any member of your firm ever been barred from doing business with any state, BOROUGH or municipal
government? If yes, then please provide further written explanation including date and copies of relevant
documentation.
Yes____
No____
_______________________
__________________
________________
Name
State, County or
Date
Municipality
(f) Has your firm sued the BOROUGH OF NEW PROVIDENCE in the past five (5) years? If yes, then please identify
the matter/case and provide further written explanation including date and copies of relevant documents.
Yes____
No____
__________________________________________
________________
Name
Date
By___________________________________
Title______________________________
16
Borough of New Providence
Prohibited Russia-Belarus Activities & Iran Investment Activities
COMPANY, PERSON, OR ENTITY
PART 1: CERTIFICATION
COMPLETE PART 1 BY CHECKING ONE OF THE THREE BOXES BELOW
Pursuant to law, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter into or
renew a contract, for goods or services must complete the certification below prior to contract award to attest, under
penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or affiliate, is identified on the
Department of Treasury's Russia-Belarus list or Chapter 25 list as a person or entity engaging in prohibited activities in
Russia, Belarus or Iran. Before a contract for goods or services can be amended or extended, a person or entity must
certify that neither the person or entity, nor any parent entity, subsidiary, or affiliate, is identified on the Department
of Treasury's Russia-Belarus list. Both lists are found on Treasury’s website at the following web addresses:
https://www.nj.gov/treasury/administration/pdf/RussiaBelarusEntityList.pdf
www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.
As applicable to the type of contract, the above-referenced lists must be reviewed prior to completing the below
certification.
A person or entity unable to make the certification must provide a detailed, accurate, and precise description of the
activities of the person or entity, or of a parent entity, subsidiary, or affiliate, engaging in prohibited activities in Russia
or Belarus and/or investment activities in Iran. The person or entity must cease engaging in any prohibited activities
and provide an updated certification before the contract can be entered into.
If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may be provided
by law, rule, or contract, including but not limited to imposing sanctions, seeking compliance, recovering damages,
declaring the party in default, and seeking debarment or suspension of the party.
CONTRACT AWARDS AND RENEWALS
I certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or
affiliate appears on the N.J. Department of Treasury’s lists of entities engaged in prohibited activities in Russia or
Belarus pursuant to P.L. 2022, c. 3 or in investment activities in Iran pursuant to P.L. 2012, c. 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. (Skip Part 2 and sign and complete the Certification below.)
CONTRACT AMENDMENTS AND EXTENSIONS
I certify, pursuant to law, that neither the person or entity listed above, nor any parent entity, subsidiary, or
affiliate is listed on the N.J. Department of the Treasury’s lists of entities determined to be engaged in prohibited
activities in Russia or Belarus pursuant to P.L. 2022, c. 3. 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. (Skip
Part 2 and sign and complete the Certification below.)
17
Borough of New Providence
Prohibited Russia-Belarus Activities & Iran Investment Activities
IF UNABLE TO CERTIFY
I am unable to certify as above because the person or entity and/or a parent entity, subsidiary, or
affiliate is listed on the Department's Russia-Belarus list and/or Chapter 25 Iran list. I will provide a detailed,
accurate, and precise description of the activities as directed in Part 2 below, and sign and complete the
Certification below. Failure to provide such will prevent the award of the contract to the person or entity,
and appropriate penalties, fines, and/or sanctions will be assessed as provided by law.
PART 2: ADDITIONAL INFORMATION
PLEASE PROVIDE FURTHER INFORMATION RELATED TO PROHIBITED ACTIVITIES IN RUSSIA OR BELARUS
AND/OR INVESTMENT ACTIVITIES IN IRAN.
You must provide a detailed, accurate, and precise description of the activities of the person or entity, or of
a parent entity, subsidiary, or affiliate, engaging in prohibited activities in Russia or Belarus and/or
investment activities in Iran in the space below and, if needed, on additional sheets provided by you.
PART 3: CERTIFICATION OF TRUE AND COMPLETE INFORMATION
I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any
attachments there, 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 Borough of New Providence is relying on the information contained herein and
hereby acknowledge that I am under a continuing obligation from the date of this certification through the
completion of any contracts with the Borough of New Providence to notify the Borough of New Providence
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 certification. 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 agreement(s) with the Borough of New Providence, and that the
Borough of New Providence, at its option, may declare any contract(s) resulting from this certification void
and unenforceable.
Name of Company, Entity
Full Name (Print)
Title
Signature
Date
18
BUSINESS ENTITY DISCLOSURE CERTIFICATION
FOR NON-FAIR AND OPEN CONTRACTS
Required Pursuant To N.J.S.A. 19:44A-20.8
Part I – Vendor Affirmation
The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that:
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. 2023, c. 30, would bar the award of this contract in the one year period preceding January 1, 2025 to any of the
following named candidate committee or joint candidates committee representing the elected officials of the Borough
of New Providence as defined pursuant to N.J.S.A. 19:44A-3 (q) and (r).
Mayor Allen Morgan
Councilperson Nadine Geoffroy
Councilperson Diane Bilicska
Councilperson Alex Kogan
Councilperson Matthew Cumiskey
Councilperson Lisa McKnight
Councilperson Kathleen Dolan
Part II – Ownership Disclosure Certification
I certify that the list below contains the names and home addresses of all owners holding 10% or more of the issued
and outstanding stock of the undersigned.
Check the box that represents the type of business entity:
Partnership
Corporation
Sole Proprietorship
Subchapter S Corporation
Limited Partnership
Limited Liability Corporation
Limited Liability Partnership Limited Liability Company
Name of Stock or Shareholder
Home Address
Part 3 – Signature and Attestation:
The undersigned is fully aware that if I have misrepresented in whole or part 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 of
___________, 2 _____.
My Commission expires:
_________________________________
(Affiant)
____________________________
(Print name & title of affiant) (Corporate Seal)
19
BUSINESS ENTITY DISCLOSURE CERTIFICATION
FOR NON-FAIR AND OPEN CONTRACTS
Required Pursuant To N.J.S.A. 19:44A-20.8
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.
5. 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 legal person, business corporation, professional services
corporation, limited liability company, partnership, limited partnership, business trust, association or any
other legal 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 than 10% of the profits or assets of a business entity or
10% of the stock in the case of a business entity 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…
q. The term "candidate committee" means a committee established pursuant to subsection a. of section 9
of P.L.1973, c.83 (C.19:44A-9) for the purpose of receiving contributions and making expenditures.
r. the term "joint 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 least two candidates for the same elective public offices in
the same election in a legislative 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 $200 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.
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First Discovered
Mar 19, 2026
Last Info Update
Apr 30, 2026
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