SOURCE DISCLOSURE CERTIFICATION FORM
Contractor: _____________________________ Solicitation Number: _______________________________
I hereby certify and say:
I have personal knowledge of the facts set forth herein and am
authorized to make this Certification on behalf of
the Contractor.
The Contractor submits this Certification in response to the referenced contract issued by the Division of
Purchase and Property, Department of the Treasury, State of New Jersey (the "Division"), in accordance with the
requirements of
N.J.S.A.
52:34-13.2.
Instructions:
List every location where services will be performed by the Contractor and all Subcontractors.
If any of the services cannot be performed within the United States, the Contract
or shall state, with specificity the
reasons why the services cannot be so performed. Attach additional pages if necessary.
Contractor and/or
Subcontractor
Description of Services
Performance Location[s]
by Country
Reasons why services
cannot be performed in US
Any changes to the information set forth in this Certification during the term of any contract awarded under the
referenced solicitation or extension thereof will be immediately reported by the Vendor to the Director, Division of
Purchase and Property (the "Director").
The Director shall determine whether sufficient justification has been provided by the Contractor to form the basis
of his certification that the services cannot be performed in the United States and whether to seek the approval of
the Treasurer.
I understand that, after award of a contract to the Contractor, it is determined that the Contractor has shifted services
declared above to be provided within the United States to sources outside the United States, prior to a
written determination by the Director that extraordinary circumstances require the shift of services or that the
failure to shift the services would result in economic hardship to the State of New Jersey, the Contractor shall be
deemed in breach of contract, which contract will be subject to termination for cause pursuant to the State of New
Jersey Standard Terms and Conditions.
I further understand that this Certification is submitted on behalf of the Contractor in order to induce the Division to
accept a bid proposal, with knowledge that the Division is relying upon the truth of the statements contained
herein.
I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if
any of the statements are willfully false, I am subject to punishment.
Contractor:___________________________________________________
[Name of Organization or Entity]
By:_____________________________________ Title: _______________________________
Print Name:______________________________ Date:_______________________________
SDC - Revised 09/12/12
