Harley Davidson Police Road Glide

Document Submission Checklist
Purchase and Delivery of 2027 Harley Davidson Police Road Glide or
equivalent
Initial Each
Required with Item
Submission of Submitted
Bid: with Bid
Owner's (Bidder's
Checkmarks: X Initials)
X Authorized Business Agent
X NJ State Business Registration Certificate
Statement of Corporate Ownership/Certification, Pursuant to
X NJSA 52:25-24.2
Acknowledgement of Receipt of any Notice(s)
X or Revision(s) or Addenda
Disclosure of Investment Activities in Iran, Russia, and
X Belarus
Submission of Non-Collusion Affidavit (THIS FORM MUST
X BE NOTARIZED)
X Acknowledgement of Affirmative Action
X Affirmative Action Mandatory Language
X Americans With Disabilities Act
X Certificate of Insurance (upon award)
X Additional Bid and Contract Provisions
X Indemnification Form
X Bid Specs and Bid
X W-9 (upon award)
Signature: The undersigned hereby acknowledges and has submitted the above requirements.
Name of Bidder: _______________________________________________________________________
Signature of Authorized Agent: ___________________________________________________________
Name and Title: _______________________________________________________________________
Date: ______
Contact phone#: __________________ Email Address: ___________________________

NOTICE TO ALL BIDDERS
PUBLIC NOTICE IS HEREBY GIVEN that sealed bids will be received by the Board of Commissioners
of the Township of Long Beach, County of Ocean, State of New Jersey for the following in the Municipal
Clerk's Office, 6805 Long Beach Blvd., Brant Beach, NJ:
Purchase and Delivery of 2027 Harley Davidson Police Road Glide or
equivalent
until October 21, 2026, 10:00am. at which time and place they will be publicly opened and read aloud. No
facsimile copies of the bids will be accepted. Specifications and other bid information may be obtained at
the Purchasing Office of the Township of Long Beach, 6805 Long Beach Blvd., Brant Beach, NJ 08008
(609-361-6635) during regular business hours 9:00 a.m. to 4:00 p.m. and on the municipal website,
www.longbeachtownship.com. Mailing of bid documents will be made at the bidders' cost. All bid
Addenda will be issued on the website. Therefore, all interested respondents should check the above website
now through the bid opening. It is the sole responsibility of the respondent to be knowledgeable of all
addenda related to this procurement.
Bidders are required to comply with the requirements of N.J.S.A. 10:5-31, et seq., and N.J.A.C. 17:27-1, et
seq.
Bidders are required to comply with the requirements of P.L. 1977, c.33; and P.L. 1999, c.238, "The Public
Works Registration Act," if applicable.
The Minimum Wage rates, if applicable, for labor employed on these contracts shall be as specified in the
"The New Jersey Prevailing Wage Rate Determination," of the New Jersey Department of Labor and
Industry.
The Township hereby reserves the right to consider the bids for sixty (60) days after the receipt thereof.
The Township further reserves the right, which is understood and agreed to by all bidders, to award the
contract award to the lowest responsible bidder based on the lowest total bid amount and to make such
awards or take such action as may be in the best interest of the Township. The Township further reserves
the right to make multiple awards for this contract, to sever and make awards of all or part of any bid to one
or more bidder, to reject any or all bids due to defects or failure to adhere to the specifications or for any
reason, or to waive informalities and accept any bid that in its judgment will be in the best interest of the
Township.
Katlyn Kerlin QPA

STATEMENT OF OWNERSHIP
DISCLOSURE CERTIFICATION
N.J.S.A. 52:25-24.2 (P.L. 1977, c.33)
No corporation, partnership, limited partnership, limited liability corporation, limited liability partnership,
Subchapter S corporation, or sole proprietorship shall be awarded a contract for the performance of any
work or the furnishing of any materials or supplies unless prior to the receipt of the bid or accompanying
the bid of said corporation, partnership, limited partnership, limited liability corporation, limited liability
partnership, Subchapter S corporation, or sole proprietorship there is submitted a statement setting forth the
names and addresses of all stockholders who own ten percent (10%) or more of the stock of any class or of
all individual partners who own a ten percent (10%) or greater interest therein. If one or more such
stockholder is itself a corporation or partnership, the stockholders holding ten percent (10%) or more of
that corporation's stock, or the individual partners owning 10% or greater interest in that partnership, as the
case may be, shall also be listed. The disclosure shall be continued until the names and addresses of every
non-corporate stockholder and individual partner exceeding the 10% ownership criteria established in this
act has been listed. This form shall be signed and submitted with the bid whether or not a stockholder or
partner owns less than 10% of the business submitting the bid.
The Attorney General has concluded that the provisions of N.J.S.A. 52:25-24.2, in referring to corporations
and partnerships, are intended to apply to all forms of corporations and partnerships, including, but not
limited to, limited partnerships, limited liability corporations, limited liability partnerships, and Subchapter
S corporations.
Bidders are required to disclose whether they are a partnership, corporation, or sole proprietorship. The
Stockholder Disclosure Certification form shall be completed, signed, and notarized. Failure of the bidder
to submit the required information is cause for automatic rejection of the bid.

STATEMENT OF OWNERSHIP DISCLOSURE
N.J.S.A. 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43)
This statement shall be completed, certified to, and included with all bid and proposal submissions.
Failure to submit the required information is cause for automatic rejection of the bid or proposal.
Name of Organization:_________________________________________________________
Organization Address:_________________________________________________________
Part I Check the box that represents the type of business organization:
Part I Check the box that represents the type of business organization:
Sole Proprietorship (skip Parts II and III, execute certification in Part IV)
Non-Profit Corporation (skip Parts II and III, execute certification in Part IV)
For-Profit Corporation (any type) Limited Liability Company (LLC)
Partnership Limited Partnership Limited Liability Partnership (LLP)
Other (be specific): ______________________________________________
Part II
The list below contains the names and addresses of all stockholders in the corporation who own
10 percent or more of its stock, of any class, or of all individual partners in the partnership who
own a 10 percent or greater interest therein, or of all members in the limited liability company
who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST
BELOW IN THIS SECTION)
OR
No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no
individual partner in the partnership owns a 10 percent or greater interest therein, or no member in
the limited liability company owns a 10 percent or greater interest therein, as the case may be.
(SKIP TO PART IV)
(Please attach additional sheets if more space is needed):
Name of Individual or Business Entity Home Address (for Individuals) or Business Address
Part III DISCLOSURE OF 10% OR GREATER OWNERSHIP IN THE STOCKHOLDERS,
PARTNERS OR LLC MEMBERS LISTED IN PART II
If a bidder has a direct or indirect parent entity which is publicly traded, and any person holds a 10
percent or greater beneficial interest in the publicly traded parent entity as of the last annual federal
Security and Exchange Commission (SEC) or foreign equivalent filing, ownership disclosure can be
met by providing links to the website(s) containing the last annual filing(s) with the federal Securities and
Exchange Commission (or foreign equivalent) that contain the name and address of each person holding a
10% or greater beneficial interest in the publicly traded parent entity, along with the relevant page numbers

of the filing(s) that contain the information on each such person. Attach additional sheets if more space
is needed.
Website (URL) containing the last annual SEC (or foreign equivalent) filing Page #'s
Please list the names and addresses of each stockholder, partner or member owning a 10 percent or greater
interest in any corresponding corporation, partnership, and/or limited liability company (LLC) listed in Part
II other than for any publicly traded parent entities referenced above. The disclosure shall be continued
until names and addresses of every noncorporate stockholder, and individual partner, and member
exceeding the 10 percent ownership criteria established pursuant to N.J.S.A. 52:25-24.2 has been listed.
Attach additional sheets if more space is needed.
Stockholder/Partner/Member and Home Address (for Individuals) or Business Address
Corresponding Entity Listed in Part II
Part IV Certification
I, being duly sworn upon my oath, hereby represent that the foregoing information and any attachments thereto
to the best of my knowledge are true and complete. I acknowledge: that I am authorized to execute this
certification on behalf of the bidder/proposer; that the Township of Long Beach is relying on the information
contained herein and that I am under a continuing obligation from the date of this certification through the
completion of any contracts with Township of Long Beach to notify the Township of Long Beach in writing
of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false
statement or misrepresentation in this certification, and if I do so, I am subject to criminal prosecution under
the law and that it will constitute a material breach of my agreement(s) with the, permitting the Township of
Long Beach to declare any contract(s) resulting from this certification void and unenforceable.
Full Name (Print): Title:
Signature: Date:

ACKNOWLEDGMENT OF RECEIPT OF NOTICE, OR ADDENDA, OR REVISIONS TO THE
ADVERTISEMENT OF BID DOCUMENTS
ACKNOWLEDGMENT OF RECEIPT OF ADDENDA
The undersigned Bidder hereby acknowledges receipt of the following Addenda:
Addendum Number Dated Acknowledge Receipt
(initial)
_______________ _______________ ____________
_______________ _______________ ____________
_______________ _______________ ____________
_______________ _______________ ____________
No addenda were received:
Acknowledged for: __________________________________________
(Name of Bidder)
By: _________________________________________
(Signature of Authorized Representative)
Name: ______________________________________
(Print or Type)
Title: ________________________________________
Date: ________________________________________

STANDARD BID DOCUMENT REFERENCE
Name of Form COMBINED CERTIFICATION: PROHIBITED ACTIVITIES IN RUSSIA AND BELARUS &
INVESTMENT ACTIVITIES IN IRAN
P.L. 2022, c. 3
Statutory Reference
N.J.S.A. 52:32-55 et seq.
N.J.S.A. 40A:11-2.1
N.J.S.A. 18A:18A-49.4
Y/N Mandatory Optional N/A
Goods and
Applicability LPCL Y Services X
PSCL Y Construction X
Instructions
Reference
P.L. 2022, c. 3 prohibits the award, renewal, amendment, or extension of State and local public
Description
contracts for goods or services with persons or entities engaging in prohibited activities in Russia or
Belarus. P.L. 2012, c.25 prohibits the award or renewal of State and local public contracts for goods
and services with persons or entities engaged in certain investment activities in the energy or finance
sectors of Iran.
Before a goods and services contract can be entered into, vendors and contractors must certify that
neither they nor any parent entity, subsidiary, or affiliate is listed on the New Jersey Department of
the Treasury's list of entities determined to be engaged in prohibited activities in Russia or Belarus
pursuant to P.L. 2022, c. 3 ("Russia-Belarus list") or in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25
list").

Prohibited Russia-Belarus Activities & Iran Investment Activities
Person or Entity
Part 1: Certification
COMPLETE PART 1 BY CHECKING ONE OF THE THREE BOXES BELOW
Pursuant to law, any person or entity that is a successful bidder or proposer, or otherwise proposes to enter
into or renew a contract, for goods or services must complete the certification below prior to contract award
to attest, under penalty of perjury, that neither the person or entity, nor any parent entity, subsidiary, or
affiliate, is identified on the Department of Treasury's Russia-Belarus list or Chapter 25 list as a person or
entity engaging in prohibited activities in Russia, Belarus or Iran. Before a contract for goods or services
can be amended or extended, a person or entity must certify that neither the person or entity, nor any parent
entity, subsidiary, or affiliate, is identified on the Department of Treasury's Russia-Belarus list. Both lists
are found on Treasury's website at the following web addresses:
https://www.nj.gov/treasury/administration/pdf/RussiaBelarusEntityList.pdf
www.state.nj.us/treasury/purchase/pdf/Chapter25List.pdf.
As applicable to the type of contract, the above-referenced lists must be reviewed prior to completing the
below certification.
A person or entity unable to make the certification must provide a detailed, accurate, and precise description
of the activities of the person or entity, or of a parent entity, subsidiary, or affiliate, engaging in prohibited
activities in Russia or Belarus and/or investment activities in Iran. The person or entity must cease engaging
in any prohibited activities and provide an updated certification before the contract can be entered into.
If a vendor or contractor is found to be in violation of law, action may be taken as appropriate and as may
be provided by law, rule, or contract, including but not limited to imposing sanctions, seeking compliance,
recovering damages, declaring the party in default, and seeking debarment or suspension of the party.
CONTRACT AWARDS AND RENEWALS
I certify, pursuant to law, that neither the person or entity listed above, nor any parent
entity, subsidiary, or affiliate appears on the N.J. Department of Treasury's lists of
entities engaged in prohibited activities in Russia or Belarus pursuant to P.L. 2022,

c. 3 or in investment activities in Iran pursuant to P.L. 2012, c. 25 ("Chapter 25
List"). I further certify that I am the person listed above, or I am an officer or
representative of the entity listed above and am authorized to make this certification
on its behalf. (Skip Part 2 and sign and complete the Certification below.)

CONTRACT AMENDMENTS AND EXTENSIONS
I certify, pursuant to law, that neither the person or entity listed above, nor any parent
entity, subsidiary, or affiliate is listed on the N.J. Department of the Treasury's lists
of entities determined to be engaged in prohibited activities in Russia or Belarus

pursuant to P.L. 2022, c. 3. I further certify that I am the person listed above, or I
am an officer or representative of the entity listed above and am authorized to make
this certification on its behalf. (Skip Part 2 and sign and complete the Certification
below.)
IF UNABLE TO CERTIFY
I am unable to certify as above because the person or entity and/or a parent entity,
subsidiary, or affiliate is listed on the Department's Russia-Belarus list and/or
Chapter 25 Iran list. I will provide a detailed, accurate, and precise description of

the activities as directed in Part 2 below, and sign and complete the Certification
below. Failure to provide such will prevent the award of the contract to the person
or entity, and appropriate penalties, fines, and/or sanctions will be assessed as
provided by law.
Part 2: Additional Information
PLEASE PROVIDE FURTHER INFORMATION RELATED TO PROHIBITED ACTIVITIES IN
RUSSIA OR BELARUS AND/OR INVESTMENT ACTIVITIES IN IRAN.
You must provide a detailed, accurate, and precise description of the activities of the person or entity, or of
a parent entity, subsidiary, or affiliate, engaging in prohibited activities in Russia or Belarus and/or
investment activities in Iran in the space below and, if needed, on additional sheets provided by you.

Part 3: Certification of True and Complete Information
I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any
attachments there, to the best of my knowledge, are true and complete. I attest that I am authorized to
execute this certification on behalf of the above-referenced person or entity.
I acknowledge that the Contracting Unit is relying on the information contained herein and hereby
acknowledge that I am under a continuing obligation from the date of this certification through the
completion of any contracts with the Contracting Unit to notify the Contracting Unit in writing of any
changes to the answers of information contained herein.
I acknowledge that I am aware that it is a criminal offense to make a false statement or
misrepresentation in this certification. If I do so, I recognize that I am subject to criminal prosecution
under the law and that it will also constitute a material breach of my agreement(s) with the Contracting
Unit and that the Contracting Unit at its option may declare any contract(s) resulting from this
certification void and unenforceable.
Full Name (Print)
Title
Signature Date