ࡱ> + bjbj 8vDhvDh.#|||||8L ! ! ! ! !U$T$$݉߉߉߉߉߉߉$jj|$U$U$$$|| ! !5؊)))$F| !| !݉)$݉))Jwq\kx !/k %sBɉ0tVԐ%&Ԑkx,xԐ|qyX$$)$$$$$' $$$$$$$Ԑ$$$$$$$$$X B:  STANDARD BID DOCUMENT REFERENCEName of Form:FEDERAL NON-DEBARMENT CERTIFICATIONStatutory Reference:N.J.S.A. 52:32-44.1 (P.L. 2019, c.406)Description:Meets statutory criteria for certification of non-debarment by a federal government agency. Summary of the Certification Requirements under N.J.S.A. 52:32-44.1 Pursuant to state law any natural person, company, firm, association, corporation, or other entity prohibited, or debarred, from contracting with the federal government agencies, shall also be prohibited from contracting for public work in the state of ӣƵ. This prohibition also extends to any affiliate organization(s) held by or subject to the control of an entity of that prohibited person or entity. Prior to awarding a contract for public work a local units must obtain written certification from the contracting person or entity through the form below, attesting to their non-debarment from contracting with federal government agencies. Contracting units are reminded that they must fill-in the boilerplate information in the certification sections of Parts II through IV regarding their name and type of contracting unit before using the form. CERTIFICATION OF NON-DEBARMENT FOR FEDERAL GOVERNMENT CONTRACTS N.J.S.A. 52:32-44.1 (P.L. 2019, c.406) This certification shall be completed, certified to, and submitted to the contracting unit prior to contract award, except for emergency contracts where submission is required prior to payment. PART I: VENDOR INFORMATIONIndividual or Organization NamePhysical Address of Individual or OrganizationUnique Entity ID (if applicable)CAGE/NCAGE Code (if applicable)Check the box that represents the type of business organization:pSole Proprietorship (skip Parts III and IV) pNon-Profit Corporation (skip Parts III and IV) pFor-Profit Corporation (any type) pLimited Liability Company (LLC) pPartnership pLimited Partnership pLimited Liability Partnership (LLP) pOther (be specific): ______________________________________________ PART II CERTIFICATION OF NON-DEBARMENT: Individual or OrganizationI hereby certify that the individual or organization listed above in Part I is not debarred by the federal government from contracting with a federal agency. I further acknowledge: that I am authorized to execute this certification on behalf of the above-named organization; that the is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the date of contract award by to notify the in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the , permitting the to declare any contract(s) resulting from this certification void and unenforceable.Full Name (Print):Title:Signature:Date: PART III CERTIFICATION OF NON-DEBARMENT: Individual or Entity Owning Greater than 50 Percent of OrganizationSection A (Check the Box that applies) pBelow is the name and address of the stockholder in the corporation who owns more than 50 percent of its voting stock, or of the partner in the partnership who owns more than 50 percent interest therein, or of the member of the limited liability company owning more than 50 percent interest therein, as the case may be.Name of Individual or OrganizationPhysical AddressOR pNo one stockholder in the corporation owns more than 50 percent of its voting stock, or no partner in the partnership owns more than 50 percent interest therein, or no member in the limited liability company owns more than 50 percent interest therein, as the case may be.Section B (Skip if no Business entity is listed in Section A above) pBelow is the name and address of the stockholder in the corporation who owns more than 50 percent of the voting stock of the organizations parent entity, or of the partner in the partnership who owns more than 50 percent interest in the organizations parent entity, or of the member of the limited liability company owning more than 50 percent interest in organizations parent entity, as the case may be.Stockholder/Partner/Member Owning Greater Than 50 Percent of Parent EntityPhysical AddressOR pNo one stockholder in the parent entity corporation owns more than 50 percent of its voting stock, no partner in the parent entity partnership owns more than 50 percent interest therein, or no member in the parent entity limited liability company owns more than 50 percent interest therein, as the case may be. Section C Part III CertificationI hereby certify that no individual or organization that is debarred by the federal government from contracting with a federal agency owns greater than 50 percent of the Organization listed above in Part I or, if applicable, owns greater than 50 percent of a parent entity of . I further acknowledge: that I am authorized to execute this certification on behalf of the above-named organization; that the is relying on the information contained herein and that I am under a continuing obligation from the date of this certification through the date of contract award to notify the in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the , permitting the to declare any contract(s) resulting from this certification void and unenforceable.Full Name (Print):Title:Signature:Date: Part IV CERTIFICATION OF NON-DEBARMENT: Contractor Controlled EntitiesSection A pBelow is the name and address of the corporation(s) in which the Organization listed in Part I owns more than 50 percent of voting stock, or of the partnership(s) in which the Organization listed in Part I owns more than 50 percent interest therein, or of the limited liability company or companies in which the Organization listed above in Part I owns more than 50 percent interest therein, as the case may be.Name of Business EntityPhysical Address**Add additional sheets if necessary**OR p !"./0ESTUijvy}  9 A B \ s % 8 9 n Ǽ񰵵 h9 \ hJiXh9 hVTh9 5>*\hJiXh9 5>*\ h9 5>* hMh<] h<]5\ h<]CJh<]h9 h9 5\hpHE!"0Ttt $Ifgd681hkd$$Ifl4`''0'44 laf4yt<]$ $Ifa$gd681gdnTUj|o $Ifgd681 $Ifgd681ykd|$$Ifl40`'|P0'44 laf4yt<]zz $Ifgd681{kd$$Ifl40 `'Xt0'44 laf4yt<]B ~vlddd~~vv$a$gd`k $xa$gd9 $a$gd9 gd9 {kd$$Ifl40 `'Xt0'44 laf4yt<]    1 C d v   & W e    ! 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Section B (skip if no business entities are listed in Section A of Part IV)pBelow are the names and addresses of any entities in which an entity listed in Part III A owns greater than 50 percent of the voting stock (corporation) or owns greater than 50 percent interest (partnership or limited liability company).Name of Business Entity Controlled by Entity Listed in Section A of Part IVPhysical Address**Add additional Sheets if necessary**ORpNo entity listed in Part III A owns greater than 50 percent of the voting stock in any corporation or owns greater than 50 percent interest in any partnership or limited liability company.Section C Part IV CertificationI hereby certify that the Organization listed above in Part I does not own greater than 50 percent of any entity that that is debarred by the federal government from contracting with a federal agency and, if applicable, does not own greater than 50 percent of any entity that in turns owns greater than 50 percent of any entity debarred by the federal government from contracting with a federal agency. 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