NJSDA Contract No:
Contract Name:
Bidder Name:
Bidder Address:
I, the undersigned, being duly authorized to complete this certification on behalf of the above-named Bidder, hereby certify
and attest, under penalty of perjury, that the above-named Bidder is not currently debarred from public contracting by any
agency of the federal government, of New Jersey government, or by agencies or authorities of other states; and (2) has not
been convicted of a crime in New Jersey that it has not previously disclosed to the NJSDA.
I further certify that no Key Person of the Bidder has been convicted of a crime. “Key Person” means any individual
employed by the Bidder in a supervisory capacity or empowered to make discretionary decisions with respect to bids and/or
contracts with the State of New Jersey. “Key Person” also means any person who owns a beneficial interest of 10% or more
in the Bidder, and the managing members of limited liability companies and corporate directors and officers (e.g., president,
vice presidents, secretary and treasurer.) For purposes of this Certification, “supervisory capacity or empowered to make
discretionary decisions” means able to bind the Bidder to New Jersey bids and/or contracts of $50,000 or more and/or
authorized to sign checks to make payments of $50,000 or more in connection with New Jersey contracts.
The Bidder must complete and submit this Certification Form prior to the award of the above-referenced Contract.
If the NJSDA finds a person or entity to be in violation of the law, it shall take action as may be appropriate and permitted
by law, rule or contract, including but not limited to, imposing sanctions, seeking compliance, recovering damages,
declaring the party in default and/or seeking debarment or suspension of the party.
I, the undersigned, certify that I am authorized to execute this certification on behalf of the Bidder, and that the foregoing
information and any attachments hereto, are true and complete. I acknowledge that the NJSDA is relying on the information
contained herein, and that the Bidder is under a continuing obligation from the date of this certification through the
completion of any contract(s) with the NJSDA to notify the NJSDA in writing of any changes to the information contained
herein. I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do
so, I will be subject to criminal prosecution under the law, and it will constitute a material breach of my agreement(s) with
the NJSDA, permitting the NJSDA to declare any contract(s) resulting from this certification void and unenforceable.
Print Name:
April 23, 2020 CMI
click to sign
click to edit