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l'l.J. LlCIJWLllCHl VI llCè1:Sury - Llivi:sivn UI K.evenue, un-Line inquiry rage i or i . Taxpayer Name: Trade Name: Address: Certifcate Number: Effective Date: Date of Issuance: For Office Use Only: 20091026145155264 STATE OF NEW JERSEY BUSINESS REGISTRATION CERTIFICATE HORION HEALTH CENTER AFFAIRS 714 BERGEN AVENUE JERSEY CITY, NJ 07306-4802 0064047 July 01, 1966 October 26, 2009 htts://ww1.state.nj.us/TYT_BRC/servlet/common/RCLogin 10/26/2009
C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Public Agency Instructions This page provides guidance to public agencies entering into contracts with business entities that are required to fie Political Contribution Disclosure forms with the agency. It is not intended to be provided to contractors. What follows are instructions on the use of form local unts can provide to contractors that are required to disclose political contributions pursuant to N.J.S.A. 19:44A-20.26 (P.L. 2005, c. 271, s.2). Additional inormation on the process is available in Local Finance Notice 2006-1 (ww.nj.gov/dca/lgs/lfns/lfnmenu.shtml). 1. The disclosure is required for all contracts in excess of$l 7,500 that are not awarded pursuant to a "fair and open" process (N.L.S.A. 19:44A-20.7). 2. Due to the potential lengt of some contractor submissions, the public agency should consider allowing data to be submitted in electronic form (i.e., spreadsheet, pdf fie, etc.). Submissions must be kept with the contrct documents or in an appropriate computer file and be available for public access. The form is worded to accept this alternate submission. The text should be amended if electronic submission will not be allowed. 3. The submission must be received from the contractor and on fie at least 10 days prior to award of the contract. Resolutions of award should reflect that the disclosure has been received and is on fie. 4. The contractor must disclose contrbutions made to candidate and part committees covering a wide range of public agencies, including all public agencies that have elected offcials in the county of the public agency, state legislative positions, and various state entities. The Division of Local Governent Services recommends that contractors be provided a list of the affected agencies. This wil assist contrctors in determining the campaign and political committees of the offcials and candidates affected by the disclosure. a. The Division has prepared model disclosure forms for each county. They can be downloaded :fom the "County PCD Forms" link on the Pay-to-Play web site at ww.nj.gov/dca/lgs/p2p. They wil be updated :fom time-to-time as necessar. b. A public agency using these forms should edit them to properly reflect the correct legislative district(s). As the forms are county-based, they list all legislative districts in each county. Districts that do not represent the public agency should be removed from the lists. c. Some contractors may find it easier to provide a single list that covers all contributions, regardless of the county. These submissions are appropriate and should be accepted. d. The form may be used "as-is", subject to edits as described herein. e. The "Contractor Instrctions" sheet is intended to be provided with the form. It is recommended that the Instrctions and the form be prited on the same piece of paper. The form notes that the Instrctions are printed on the back of the form; where that is not the case, the text should be edited accordingly. f. The form is a Word document and can be edited to meet local needs, and posted for download on web sites, used as an e-mail attchment, or provided as a printed document. 5. It is recommended that the contractor also complete a "StockhoIder Disclosure Certification." This wil assist the local unit in its obligation to ensure that contractor did not make any prohibited contributions to the committees listed on the Business Entity Disclosure Certification in the 12 months prior to the contract. (See Local Finance Notice 2006-7 for additional information on this obligation) A sample Certification form is par of this package and the instrction to complete it is included in the Contractor Instrctions. NOTE: This section is not applicable to Boards of Education.
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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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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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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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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
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Questionnaire for Bidders Jersey Ci
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" Treasurer ~: State Certification
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,"" -' CERTIFICATION IN SUPPORT OF
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Consulting Services Agreement For t
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A. The selected consultant shall pu
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The parties hereto reserve the righ
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A business organization that fails
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This Agreei:ent dated the AGREEMENT
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approved in advance for any specifi
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et seq. 2. An Affirmative Action Em
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City Clerk File No. Pg. #-- Agenda
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month an affidavit of services spec
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The City does not agree to pay for
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administration of this contract. Al
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such as court reporters, investigat
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The City does not agree to pay for
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AGREEMENT . Ths Agreement dated the
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Should the services of one or more
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affixed the day, month and year abo
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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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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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MINORITY/wOMAN BUSINESS ENTERPRISE
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Page 319 and 320: Princeton Insurance Company COMMON
Page 321 and 322: . BUSINESS ENTITY DISCLOSUR CERTIFI
Page 323 and 324: City Clerk File No. Agenda No. Appr
Page 329 and 330: Continuation of Resolution City Cle
Page 331 and 332: Requisition # 0148192 . Vendor EDUC
Page 333 and 334: EEO/ AFFIRMATIVE ACTION REQUIREMENT
Page 335 and 336: EXHIBIT A (Cont.) The contractor or
Page 338 and 339: MINORITYIWOMAN BUSINESS ENTERPRISE
Page 340 and 341: P.L. 2004, c. 57 (N.J.S.A. 52:32-44
Page 342 and 343: , .' C. 271 POLITICAL CONTRIBUTION
Page 344 and 345: C. 271 POUTICAL CONTRIBUTION DISCLO
Page 346 and 347: List of Agencies with Elected Offic
Page 348 and 349: BUSINESS ENTITY DISCLOSURE CERTIFIC
Page 350 and 351: AGREEMENT THIS AGREEMENT entered in
Page 352 and 353: 6. Purchases C) The City may send a
Page 354 and 355: 12. Retention of Records Financial
Page 356 and 357: 17. Labor Standards All laborers an
Page 358 and 359: Requisition # 0148794 Vendor HORIZO
Page 360 and 361: EEOIAFFIRMATIVE ACTION --REQUIREMEN
Page 362 and 363: EXHIBIT A (Cont.) The contractor or
Page 364 and 365: State Treasurer HORIZON HEALTH CENT
Page 370 and 371: C. 271 POLITICAL CONTRIBUTION DISCL
Page 372 and 373: Page_of Vendor Name: Continuation P
Page 376 and 377: CERTIFICATION OF COMPLIANCE WITH TH
Page 378 and 379: 3. Compliance with Approved Program
Page 380 and 381: B) Subgrantees that receive at leas
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Page 384 and 385: 20. Political Activity Prohibited N
Page 386 and 387: DETERMNATION OF VALUE CERTIFICATION
Page 388 and 389: EXHIBIT A MANDATORY EQUAL EMPLOYMEN
Page 390 and 391: APPENDIX A AMERICANS WITH DISABILIT
Page 392 and 393: Page L ot3 Public Contracts Equal E
Page 396 and 397: P.L. 2004, c. 57 (N.J.S.A. 52:32~44
Page 398 and 399: N.J. uepartent of Treasury - Uivisi
Page 400 and 401: C. 271 POLITICAL CONTRIBUTION DISCL
Page 402 and 403: Page_of Vendor Name: o Check here i
Page 406 and 407: CERTIFICATION OF COMPLIANCE WITH TH
Page 408 and 409: 3. Compliance with Approved Program
Page 410 and 411: B) Subgrantees that receive at leas
Page 412 and 413: comply with such additional conditi
Page 414 and 415: 20. Political Activity Prohibited N
Page 416 and 417: 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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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 DISCLO
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C. 271 POLITICAL CONTRIBUTION DISCL
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List of Agencies with Elected Offic
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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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12. Retention of Records Financial
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17. Labor Standards All laborers an
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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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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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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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MINORITYIWOMAN BUSINESS ENTERPRISE
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Page ::of 2- Vendor Name: Continuat
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BUSINESS ENTITY DISCLOSURE CERTIFIC
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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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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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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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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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Year 2010 temporary budget to make available the ... - Jersey City

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