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~HW u.cr i l.J12/2889 Hl: 14 261-547-5230 LAW DEPT CE:RTJFICA TION OF COMPLIANCE WITH THE CIT OF JERSEY CITY CONTRACTOR:lAY-TO-PLAYREFORMORDINANCE 08-128 ADOPTED ON SEPT.nMBER 3, 2008 ' P A.R T T - Ven.d.or Affrmation ~ignCd, being autbor,1.ed and Imowledgeable of the circumstances, does hereby cerify that , l.,c. ..A.çt~ (name of. busjn,ess entity) has n.ot made any reporable contributions in the .iione-yearo d preding . N,; h? ') (date City CowiciJ 128. awar.ds can,r.ract) that would be deemed to be violations ofSi:ctiQn One 'ofthe City of Jersey Cityls (name ofbusincss entity) will :rottrake any reportble contrbutions in violation of Ordinance 08- Con.tra~tor Pay-to-Play Reform, Ordinance 08- 128 (a.taelied hereto) and that would bar the award. of this contract. I further cert.ify tbat durng the: te.n:n ofthe contract~ LCd... =- --:- PART II ~ Sjgnature and Attestation: . The ut1dersi.gned is fully aware that if I have misrepresented .Íl) whole or par this affrmation and eertificalio,t1, r and/or the bU$,if.es$ entity, wil be liable for any penalty permtted under law. Signed /" Pr;ntName ("?~ -r "",L, i i Subscribed and SW.4 before mi this /"6 day of /1'/11, , 2 ",.. . ~~~~ex~~,. fi~. ßmVfV"'¡: A/ 'J .. c: A--c .A ..~ J Le- Title: .. ~""7 d le-. .Date: LL l ,::1 07 (Affant) (ptiiit,lIll"tO & l't1.t ofa;ffan,t) (Coq)Ofate Seal) UPurSU3t to Section 2 of Ordin.ance 08~ 128, no eo,ritrbutions or solicjtation of con.trbutions made prior to the: effectve date Ordinact: 08~ 128 (September 23, 2008) shall be deemed to be a, vi.olation ofthe Ordinance. PAGE 02/iel PAGE B2/24
~i/~ii~~i~ 'l~:~~ ~~1-541-523Ø . . 11/12/26a9 10: 14 2ei-547-523~ LAW DEPT LAW DEFT c. 271 POLITICAL COmiimON DISClOSRE fORM ReqUir:d Pursuant To NJ.S.A. 19:44A-20.26 . This form or its pÐrmittoè fac:lhilt must he submitted, c. the loaJ unit no )iiter thaQ 10 d nor to tl8 .ward o.the COntraci~ d-, ~ (, i e. PAGE 03/10 PAGE 11/211 being authorized to cerifY, herby ~ertifiea that tho ~bmissjDn prvided herein rep,e5ClS the prnvjsions ofN.i,a.A" i 9:44A-20.26 and IS represenred by the Inslnctions accompanying this G9~,~-T_~-b Prime Name Part 11- Contñbution Disc.losure /t-. cd l-; '1 ¡;' Title DiSclosure requirement: Pursant t'O NJ.S.A, 19:44A-20.26 tls disclos\ire must include all reportable politica COntribu.tions (more tha. 5300 pe election cycleJover the 12 months priOf to ~ubmjssion to th conininees oflhe govemment entities listd OD 1he fomiprovid.ed by the lòcal unt. o r;hêf:k here jfdiscioslJre i& provided in e1eetnic for. COJlb~tor Jiame - , " '" ."- " _.. .. .. i.. RiøClIDlent Nalt Date Doller Amount $, . ~ "-"- "-"" - " " .. "". o Cheek her J1)he irfonation is conim\\cd On subsequet page's) . .
Page 1 and 2:
City Clerk File No. Agenda No. Appr
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Continuation of Resolution City Cle
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()- 00;1 EXHIBIT A JAN i 3 2010 BLO
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Block: 00763 Principal: 3,167.01 Ta
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N N N ~ -c N m 0 0 0 0 ;i 0 0 0 0 ;
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Memo to Brian O'Reiley, Business Ad
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Resolution of the City of Jersey Ci
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LEGISLATIVE FACT SHEET This summary
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of the Licensee or anyone employed
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14. Failure to adhere to the terms
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HOST CITY AGREEMENT THIS HOST CITY
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provided in writing by the Red Bull
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on the first business day following
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(1) Severabilty. If any provision o
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SCHEDULE A SERVICES The City shall
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.. November 16, 2009 Paragraph D -
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Aricle 26 November 16, 2009 Paragra
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Aricle 30 Insert New Paragraph H as
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Aricle 36 November 16,2009 Add new
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wil be $50 per 30-day supply, meani
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CERTIFICATION OF BRIAN O'REILLY IN
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. AFTI ACTION COMPLIACE NOTICE N.J.
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EXITA N.J.s.A. 10:5-31 aDd N.J.AC.
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APPENIX A AMRICANS WI DISABIL ACT O
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" Taxpayer Identifcation# 221~896.1
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0148637 CITY OF JERSEY CITY Requisi
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A summary of Aetna's proposal rates
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City of Jersey City Dental Program
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UL-\, .L C- C-UiiO .L-i- Jc: veL I
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CERTIFICATION OF BRIAN O'REILLY IN
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-,-~._'~_.,----_._.~.._--_.- -'-~--
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EXIT A N.J.s.A. 10:5-31 and N.J.AC.
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APPENDIX A AMRICANS WI DISABIL ACT
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-~_.._- ._----~_._-~.._----_._----~
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Reqúisition # 0148636 Vendor DELTA
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. A sumary of Aetna's proposal rate
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Total Annual: Total Monthly: $158,0
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VcL-l¿-¿~~~ IJ;J¿ DEL TA DENTAL
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EXTRAORDINARY UNSPECIFIABLE SERVICE
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Requisition # 0148639 Vendor RELIAS
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EXIT A N.J.s.A.IG:5-3la.d N.J.A.C.
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APPENIX A AMRICANS WI DISABIL ACT O
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./ Resolution of the City of Jersey
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FULL TITLE OF RESOLUTION: RESOLUTIO
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61/64/2636 12: 62 9735860221 JAALE.
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01/04/2030 12: 02 9736800221 JAALEX
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. ..... ~_.... .., CITY OF JERSEY C
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12/16/2009 18: ~1 9732435549 PAG 02
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: 12/1&/2009 17: 56 , ILl 19"'1111"
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: ::. _._'.- ::-: - - CERTiF1CA l"E
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12i'6/2E1E19 17: 56 9732435549 IL/1
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12/16/2009 18: 41 9732435549 PAGE 0
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12/1&/2009 18: 41 9732435549 PAGE 6
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i.~rl.~(~ElElê l!3: ~1. '" ~H~~4~S
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":.'~" (l-~.. DEPAATUE1' OF 1'REASY
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EXHIT A 'MAATORY.EQUAL EMPLOYM OPPO
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C6r~ôn CERTIFICATE OF EMPLOYEE INF
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MioritylWoman BuSÎJess Enterprise
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.: i ..; ..' . TAXPAYER NAME: CHUKS
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AGREEMENT AGREEMENT made this _ day
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ARTICLE iv Compensation and Payment
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loss of life or property or in any
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executed by their duly authorized o
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EXBmIT A (Cant.) The contractor or
Page 169 and 170: Questionnaire for Bidders Jersey Ci
Page 171 and 172: City Clerk File No. Agenda No. Appr
Page 173 and 174: " Treasurer ~: State Certification
Page 175 and 176: Continuation of Resolution City Cle
Page 177 and 178: ,"" -' CERTIFICATION IN SUPPORT OF
Page 179 and 180: Consulting Services Agreement For t
Page 181 and 182: A. The selected consultant shall pu
Page 183 and 184: The parties hereto reserve the righ
Page 185 and 186: A business organization that fails
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Page 189 and 190: ~" ~".: J : . . .: 'f ", J i ~ ,- ~
Page 191 and 192: , " .I~""IUI lt'~ IA I: (r¡1"~ 53t
Page 193 and 194: t '. " l ~. ~ON CO~LrlMON ~A~ STATE
Page 195 and 196: ! . ¡', '" I.: " l~ . CERnFCATION
Page 199 and 200: Resolution of the City of Jersey Ci
Page 201 and 202: This Agreei:ent dated the AGREEMENT
Page 203 and 204: approved in advance for any specifi
Page 205 and 206: et seq. 2. An Affirmative Action Em
Page 207 and 208: iLliiIL~~~ lL:LL Lin -~4 1-~23Ø LA
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Page 213 and 214: 12/11/2009 12:22 201-547-5230 LAW D
Page 215 and 216: LL(iiIL~~~ l¿:¿¿ :¿1:1-54 7 -52
Page 217 and 218: 1¿/li/2ElEl9 12:22 201-547-52313 L
Page 219: City Clerk File No. Pg. #-- Agenda
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Page 225 and 226: U~'ur(~u¿u ¿~~~~ L~i-~q(-~~~~ 11/
Page 227 and 228: JRN-07-211111 15:34 trDm:2016536979
Page 231 and 232: month an affidavit of services spec
Page 233 and 234: The City does not agree to pay for
Page 235 and 236: administration of this contract. Al
Page 239 and 240: such as court reporters, investigat
Page 241 and 242: The City does not agree to pay for
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Page 263 and 264: AGREEMENT . Ths Agreement dated the
Page 265 and 266: Should the services of one or more
Page 267 and 268: affixed the day, month and year abo
Page 269 and 270: Continuation of Resolution Pg. # 2
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cents ($1.50) per page; and (ii) ch
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pursuant to section 1 ofP.L.2001, c
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l:1/l:4/2E:l: 12: 10 201-547-5230 L
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~i/04/2010 12: 10 12/3ß/zÐÐ9 iø
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01/64/2610 J.:O ,jt;l :'I:ll:l': 12
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." ~l/~q/~~lØ l2~10 1~/3e/2009 18:
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~1/tlq/2~1~ 12: 113 12/36/2e~9 i~:
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~i,~q,~~i~ l~:l~ 2~1-547-5230 12/30
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~1/Ø4/2~1~ 12: 1~ 201-547-5230 i~i
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4""'& "".. r - .j'~U LHW Ui=r-, PAG
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.&¿.. .LV Lui -J"l t -;"L.::U:I -~
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~~, u~, ¿u¿u ¿¿~iD iLI ~~I ~~~~
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the preceding month. All statements
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complete or substantially complete
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Robert Byrne City Clerk Brian O'Rei
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Continuation of Resolution Pg. # Ci
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Requisition # 0148621 Vendor SOLOMO
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City of Jersey City Department of H
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VII. RECORDS AND FILES' All patient
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EXHIBIT A (Cont.) The contractor or
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.. ". \ .~ . ..' '::' . . . .~ . ,~
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MINORITY/wOMAN BUSINESS ENTERPRISE
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-d!.~tlN~Ni~y "i"" State' Of New Je
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Princeton Insurance Company COMMON
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. BUSINESS ENTITY DISCLOSUR CERTIFI
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Requisition # 0148192 . Vendor EDUC
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EEO/ AFFIRMATIVE ACTION REQUIREMENT
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MINORITYIWOMAN BUSINESS ENTERPRISE
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P.L. 2004, c. 57 (N.J.S.A. 52:32-44
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, .' C. 271 POLITICAL CONTRIBUTION
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C. 271 POUTICAL CONTRIBUTION DISCLO
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List of Agencies with Elected Offic
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BUSINESS ENTITY DISCLOSURE CERTIFIC
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AGREEMENT THIS AGREEMENT entered in
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6. Purchases C) The City may send a
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12. Retention of Records Financial
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17. Labor Standards All laborers an
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Requisition # 0148794 Vendor HORIZO
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EEOIAFFIRMATIVE ACTION --REQUIREMEN
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State Treasurer HORIZON HEALTH CENT
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l'l.J. LlCIJWLllCHl VI llCè1:Sury
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C. 271 POLITICAL CONTRIBUTION DISCL
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Page_of Vendor Name: Continuation P
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CERTIFICATION OF COMPLIANCE WITH TH
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3. Compliance with Approved Program
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B) Subgrantees that receive at leas
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comply with such additional conditi
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20. Political Activity Prohibited N
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DETERMNATION OF VALUE CERTIFICATION
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EXHIBIT A MANDATORY EQUAL EMPLOYMEN
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APPENDIX A AMERICANS WITH DISABILIT
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Page L ot3 Public Contracts Equal E
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P.L. 2004, c. 57 (N.J.S.A. 52:32~44
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N.J. uepartent of Treasury - Uivisi
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Page_of Vendor Name: o Check here i
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DETERMINATION OF V ALUECERTIFICATIO
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EXHIBIT A MANDATORY EQUAL EMPLOYMEN
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APPENDIX A AMERICANS WITH DISABILIT
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P.L. 2004, c. 57 (N.J.S.A. 52:32-44
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C.271 POLITICAL CONTRIBUTION DISCLO
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. ~ , BUSINESS ENTITY DISCLOSURE CE
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AGREEMENT TIDS AGREEMENT entered in
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6. Purchses C) The City may send a
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ATTACHEMENT A PROGRAM DESCRIPTION:
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AGREEMENT . THIS AGREEMENT entered
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6. Purchses C) The City may send a
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ATTACHEMENT A PROGRAM DESCRIPTION:
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~. Requisition # 0148802 Vendor PHI
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EEO/ AFFIRMATIVE _.._----_._."---.
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Certification 778 CERTIFICATE OF EM
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MINORITYIWOMAN.BUSINESS ENTERPRISE
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l'l.J. UCPi:UIlCUl UL HCa:sury - Ui
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AGREEMENT THIS AGREEMENT entered in
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C) The City may send a representati
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Requisition # 0148804 Vendor . . PR
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EEO/ AFFIRMATIVE - --- - ----~- ---
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- --"- - - - -- - ----- - - - - - -
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n.J. Ui;paiulll;llt vi ill;~UlY - u
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Page ::of 2- Vendor Name: Continuat
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City Clerk File No. Pg.#~ Agenda No
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Date Submitted ORDINANCEIRSOLUTION
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'~""- " JON S. CORZINE Governor Dec
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WILLIAMR. GOBLE, P.E., CITY ENGINEE
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Grant Application for State Aid to
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Grant Application for State Aid to
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Scope of Work cant' d Grant Applica
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CITY OF JERSEY CITY o E PA R TM E N
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,..~J i. \. \.....,.. ...........-
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Engineer's Estimate (12.03-2009) IT
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Project Classification (J Pedestria
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Name of Grantee: Jersey City Organi
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;:t:dn udlldynt:.. - Un:in¡; "'t:~
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LEGISLATIVE FACT SHEET This summary
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10. Any equipment installed or used
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Cit Clerk File No. Agenda No. 10.Z.
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and fully cooperate with the Direct
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7. Plan for collection ofuutstandin
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Dated: ~ SHEET 1 Dated: Director of
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Sheet 2 RECORDED VOTE- Ayes: SO-rOL
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SHEET3A ,. SEE BUDGET APPROPRIATION
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SHEET3B_1 PRIORYEAR.'S LOCAL MUNICI
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SHEET3C Totals days 265,942 $73,979
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09-206 34,736,189 ________-:_____._
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SHEET 9 ----_....__...._------_.._-
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Click It or Ticket _.._.._-_.._---_
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01/12/10 SHEET 15A _________.._____
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01/12/10 SHEET 18A I I I 13,711 I T
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I 01/12/10 SHEET 240 I I I I , ----
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TÖTALCAPITAL IMPROVEMENTS FROM "CA
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(Tis appendix must be Included in a
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Sheet 40b C-3 TOT ALS- ALL PROJECTS
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TOTALS. ALL PROJECTS 33-399 210,155
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Sheet 44 JAN 1 3 2010 Date If you h
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