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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 of P.L. 2005, c. 271, s.2 QU.S.A. 19:44A-20.26). This law provides that 10 days prior to the award of such a contract, the contractor shall disclose contributions 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 offce: o of the 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 district 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 reportable contributions to any of the committees that exceed $300 per election cycle that were made during the 12 months prior to award ofthe contract. See N.J.S.A. 19:44A-8and 19:44A~ 16 for more details on reportble contributions. N.J.S.A. 19:44A-20.26 itemizes the parties from whom contributions must be disclosed when a business entity is not a natural person. This includes the following: 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 ~ individuals with an "interest" ownership or control.ofmore than 10% of · all principals, parers, officers, 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 organiztions, directly or indirectly controlled by the business entity and filing as continuing political committees, (PACs). When the business entity is a natural person, "a contribution by that person's spouse or child, residing therewith, shall be deemed to be a contribution by the business entity." (N.J.S.A. 19:44A-20.26(b)J The contributor must be listed on the disclosure. Any business entity that fails to comply with the disclosure provisions shall be subject to a fine 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 identifying those public agencies whose elected offcial and/or candidate campaign committees are affected by the disclosure requirement. It is the contractor's responsibility to identify the specific committees to which contrbutions may have been made and need to be disclosed. The disclosed information may exceed the minimum requirement. The enclosed form, a content-consistent facsimile, or an electronic data fie 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 contrctor 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 commitee established, authorized to be established, or designated by the President of General Assembly or the Minority Leader of the Senate, the Minority Leader of the Senate, the Speaker of the General Assembly pursuant to section 16 ofP.L.1993,c.65 the . (C.19:44A-l 0.1) for the purose of receiving contributions and making expenditures."
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 of the contract. L'/ .r.S I tV L C (-- c.'Le. State: ./1 7- Zi: 0 (f The undersigned being authorized to certify, hereby certifies that the submissiorrrovided herein represents compliance with the provisions ofN.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this form. ii 7~, ~LS7~- Printed Name Part II - Contribution Disclosure &S(~¿~ Title Disclosure requirement: Pursuant to N.l.S.A. 19:44A-20.26 ths disclosure must include all reportble pqlitical contrbutions (more than $300 per election cycle) over the 12 months prior to submission to the commttees of the governent entities listed on the form provided by the local unt. o Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount I/V 01/) PPL (C9-ß Le $ o Check here if 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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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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. ..... ~_.... .., CITY OF JERSEY C
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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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t '. " l ~. ~ON CO~LrlMON ~A~ STATE
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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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. ; ii/12/20El9 10: ld 2131-547-523
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JRN-07-211111 15:34 trDm:2016536979
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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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12/iS/2ee9 11: 52 281-547-5230 LAW
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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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~i/04/2010 12: 10 12/3ß/zÐÐ9 iø
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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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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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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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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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Page 444 and 445: AGREEMENT . THIS AGREEMENT entered
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Page 452 and 453: ATTACHEMENT A PROGRAM DESCRIPTION:
Page 454 and 455: ~. Requisition # 0148802 Vendor PHI
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Page 458 and 459: EXHIBIT A (Cont.) The contractor or
Page 460 and 461: Certification 778 CERTIFICATE OF EM
Page 462 and 463: MINORITYIWOMAN.BUSINESS ENTERPRISE
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Page 466 and 467: C. 271 POLITICAL CONTRIBUTION DISCL
Page 468 and 469: List of Agencies with Elected Offic
Page 470 and 471: BUSINESS ENTITY DISCLOSURE CERTIFIC
Page 472 and 473: AGREEMENT THIS AGREEMENT entered in
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Page 480 and 481: Requisition # 0148804 Vendor . . PR
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Page 494 and 495: Page ::of 2- Vendor Name: Continuat
Page 496 and 497: BUSINESS ENTITY DISCLOSURE CERTIFIC
Page 498 and 499: CERTIFICATION OF COMPLIANCE WITH TH
Page 500 and 501: 3. Compliance with Approved Program
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Page 508 and 509: City Clerk File No. Pg.#~ Agenda No
Page 510 and 511: Date Submitted ORDINANCEIRSOLUTION
Page 512 and 513: Continuation of Resolution City Cle
Page 514 and 515: '~""- " JON S. CORZINE Governor Dec
Page 516 and 517: WILLIAMR. GOBLE, P.E., CITY ENGINEE
Page 518 and 519: Grant Application for State Aid to
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Page 522 and 523: Scope of Work cant' d Grant Applica
Page 524 and 525: CITY OF JERSEY CITY o E PA R TM E N
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Page 536 and 537: Engineer's Estimate (12.03-2009) IT
Page 538 and 539: Project Classification (J Pedestria
Page 540 and 541: 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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