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C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Contractor Instructions Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to a "fair and open" process (defined at N.J.S.A. 19:44A-20.7) are subject to the provisions ofP.L. 2005, c. 271, s.2 (N.J.S.A. 19:44A-~0.26). This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contrbutions to: · any State, county, or municipal committee of a political par · any legislative leadership committee. · any continuing political committee (a.k.a., political action committee) · any candidate committee of a candidate for, or holder of, an elective office: o ofthe public entity awarding the contract o of that county in which that public entity is located o of another public entity within that county o or of a legislative distrct in which that public entity is located or, when the public entity is a county, of any legislative district which includes all or par of the county The disclosure must list reportble contributions to any of the committees that exceed $300 per election cycle that were made during the 12 months prior to award of the contract. See N.J.S.A. 19:44A-8 and 19:44A-16 for more details on reportble contributions. N.J.S.A. 19:44A-20.26 itemizes the paries from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: · individuals with an "interest" ownership or control of more than 10% of the profits or assets of a business entity or 10% of the stock in the case of a business entity that is a corporation for profit · all principals, parters, offcers, or directors of the business entity or their spouses · any subsidiaries directly or indirectly controlled by the business entity · IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by the business entity and filing as continuing political committees, (PACs). When the business entity is a natural person, "a contrbution by that person's spouse or child, residing therewith, shall be deemed to be a contrbution by the business entity." (N.J.S.A. 19:44A-20.26(b)) The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall be subject to a fme imposed by ELEC in an amount to be determined by the Commission which may be based upon the amount that the business entity failed to report. The enclosed list of agencies is provided to assist the contractor in identifing those public agencies whose elected offcial and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor's responsibilty to identify the specific committees to which contributions may have been made and need to be disclosed. The disclosed inormation may exceed the minimum requirement. The enclosed form, a content-consistent facsimile, or an electronic data file containing the required details (along with a signed cover sheet) may be used as the contractor's submission and is disclosable to the public under the Open Public Records Act. The contractor must also complete the attched Stockholder Disclosure Certification. This wil assist the agency in meeting its obligations under the law. NOTE: This section does not apply to Board of Education contracts. · N.J.S.A. 19:44A-3(s): "The term "legislative leadership committee" means a commttee established, authoried to be establisht:d, or designated by the President of the Senate, the Minority Leader of the Senate, the Speaker of the General Assembly or the Miority Leader of the General Assembly pursuant to section 16 ofP.L.1993, c.65 (C. 19:44 A -10.1) for the purose of receivig contrbutions and making expenditues."
C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20.26 This form or its permitted facsimile must be submitted to the local unit no later than 10 days prior to the award ofthe contract. The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisio ofN.J.S.A. 19:44A-20.26 and as represented by the Instrctions accompanying this form. I!rt lid l\ cl~w..') Printed Nlme Coo Title Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contrbutions (more than $300 per election cycle) over the 12 months prior to submission to the committees of the governent entities listed on the form provided by the local unit. D Check here if disclosure is provided in electronic form. D Check here if Contributor Name Recipient Name Date Dollar Amount $ the information is continued on subsequent page(s)
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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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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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":.'~" (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
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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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! . ¡', '" I.: " l~ . CERnFCATION
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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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-d!.~tlN~Ni~y "i"" State' Of New Je
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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
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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
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Page 360 and 361: EEOIAFFIRMATIVE ACTION --REQUIREMEN
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Page 364 and 365: State Treasurer HORIZON HEALTH CENT
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Page 372 and 373: Page_of Vendor Name: Continuation P
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Page 386 and 387: DETERMNATION OF VALUE CERTIFICATION
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Page 390 and 391: APPENDIX A AMERICANS WITH DISABILIT
Page 392 and 393: Page L ot3 Public Contracts Equal E
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Page 406 and 407: CERTIFICATION OF COMPLIANCE WITH TH
Page 408 and 409: 3. Compliance with Approved Program
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Page 416 and 417: DETERMINATION OF V ALUECERTIFICATIO
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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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MINORITYIWOMAN BUSINESS ENTERPRISE
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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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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 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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