Fillable Source Disclosure Certification Form printable pdf download

SOURCE DISCLOSURE CERTIFICATION FORM

Contractor: _____________________________

Solicitation Number: _______________________________

I hereby certify and say:

I have personal knowledge of the facts set forth herein and am

authorized to make this Certification on behalf of

the Contractor.

The Contractor submits this Certification in response to the referenced contract issued by the Division of

Purchase and Property, Department of the Treasury, State of New Jersey (the "Division"), in accordance with the

requirements of N.J.S.A. 52:34-13.2.

Instructions:

List every location where services will be performed by the Contractor and all Subcontractors.

If any of the services cannot be performed within the United States, the Contract

or shall state, with specificity the

reasons why the services cannot be so performed. Attach additional pages if necessary.

Contractor and/or

Performance Location[s]

Reasons why services

Description of Services

Subcontractor

by Country

cannot be performed in US

Any changes to the information set forth in this Certification during the term of any contract awarded under the

ely reported by the Vendor to the Director, Division of

referenced solicitation or extension thereof will be immediat

Purchase and Property (the "Director").

The Director shall determine whether sufficient justification has been provided by the Contractor to form the basis

services cannot be performed in the United States and whether to seek the approval of

of his certification that the

the Treasurer.

ct to the Contractor, it is determined that the Contractor has shifted services

I understand that, after award of a contra

declared above to be provided within the United States to sources outside the United States, prior to a

written determination by the Director that extraordinary circumstances require the shift of services or that the

failure to shift the services would result in economic hardship to the State of New Jersey, the Contractor shall be

deemed in breach of contract, which contract will be subject to termination for cause pursuant to the State of New

Jersey Standard Terms and Conditions.

I further understand that this Certification is submitted on behalf of the Contractor in order to induce the Division to

accept a bid proposal, with knowledge that the Divi

of the statements contained

sion is relying upon the truth

herein.

I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if

any of the statements are willfully false, I am subject to punishment.

Contractor:___________________________________________________

[Name of Organization or Entity]

By:_____________________________________ Title: _______________________________

Print Name:______________________________ Date:_______________________________

SDC - Revised 09/12/12

Source Disclosure Certification Form

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