NEW JERSEY SCHOOLS DEVELOPMENT AUTHORITY
DISCLOSURE OF INVESTMENT ACTIVITIES IN IRAN FORM
NJSDA Contract No: Project Description:
Bidder Name and Address:
PART 1
BIDDER MUST COMPLETE PART 1 BY CHECKING ONE OF THE BOXES
FAILURE TO CHECK ONE OF THE BOXES WILL RENDER THE PROPOSAL NON-RESPONSIVE
Pursuant to Public Law 2012, c. 25 (codified at N.J.S.A. 52:32-55, et seq.) (the “Act”), any person or entity that submits a bid or proposal
or otherwise proposes to enter into or renew a contract with the New Jersey Schools Development Authority (“NJSDA”) must complete
the certification below to attest, under penalty of perjury, that neither the person nor entity, nor any of its parents, subsidiaries, or
affiliates, is identified on the list created and maintained by the New Jersey Department of the Treasury (“Treasury”) (referred to
hereinafter as the “Chapter 25 List”) as a person or entity engaging in investment activities in Iran. The Chapter 25 List is located at
http://www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf. Bidders must review the Chapter 25 List prior to completing the below
certification. Failure to complete the certification and/or to submit a completed Disclosure form will render the Bidder’s proposal
non-responsive. 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.
CHECK THE APPROPRIATE BOX
A.
I certify, pursuant to the Act, that neither the Bidder listed above nor any of its parents, subsidiaries, or affiliates is
listed on the Chapter 25 List. Disregard Part 2 and complete and sign the Certification below.
B.
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 Chapter 25 List. I will provide a detailed, accurate and precise description of the activities in Part 2
and sign and complete the Certification below. Failure to provide such information will result in the proposal being
rendered as nonresponsive and appropriate penalties, fines, and/or sanctions will be assessed as provided by law.
PART 2
PLEASE PROVIDE ADDITIONAL INFORMATION RELATED TO INVESTMENT ACTIVITIES IN IRAN
If you checked Box “B” above, provide a detailed, accurate and precise description of the activities of the Bidder, or any of its parents,
subsidiaries or affiliates, engaged in the investment activities in Iran below:
ENTITY NANE:
RELATIONSHIP TO BIDDER:
DESCRIPTION OF ACTIVITIES:
DURATION OF ENGAGEMENT:
ANTICIPATED CESSATION DATE:
BIDDER CONTACT NAME:
BIDDER CONTACT PHONE NO.:
Attach Additional Sheets If Necessary.
CERTIFICATION
I, the undersigned, certify that I am authorized to execute this certification on behalf of the Bidder, 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.
Signature: Date:
Print Name and Title:
Revised: 5-2018 DIAI
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