Vendor Certification And Disclosure Of Political Contributions Form
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1
2Public Law 2005, Chapter 51
Vendor Certification and Disclosure
of Political Contributions (2 Years)
(formerly Executive Order 134)
Vendor:
EIN:
(9 digits)
The vendor should complete the required Certification and Disclosure forms and submit them, together with a completed
Ownership Disclosure form, to the using agency, department or the Purchase Bureau. Instructions for completing this
form are at
Part I: Certification
I hereby certify as follows:
1. On or after October 15, 2004, the below-named person or entity has not solicited or made any contribution of money,
pledge of contribution, including in-kind contributions, company or organization contributions, as set forth below that
would bar the award of a contract to the vendor, pursuant to the terms of Public Law 2005, Chapter 51 [N.J.S.A.
19:44A-20.13-20.25, superseding Executive Order 134 (2004)].
a) Within the preceding 18 months, the below-named person or organization has not made a contribution to
(i)
Any candidate committee and/or election fund of any candidate for or holder of the public office of
Governor; or
(ii)
Any State or county political party committee.
b) During the term of office of the current Governor (exclusive of any contributions made prior to October
15, 2004), the below-named person or organization has not made a contribution to
(i)
Any candidate, committee and/or election fund of the Governor; or
(ii)
Any State or county political party committee nominating such Governor in the election preceding the
commencement of said Governor’s term.
c) Within the 18 months immediately prior to the first day of the term of office of the Governor, (exclusive of
any contributions made prior to October 15, 2004), the below-named person or organization has not made
a contribution to
(i)
Any candidate, committee and/or election fund of the Governor; or
(ii)
Any State or county political party committee of the political party nominating the successful gubernatorial
candidate in the last gubernatorial election.
2. If the vendor is awarded a contract pursuant to this procurement process, the below-named person or organization
will, on a continuing basis, continue to report any contributions it makes during the term of the contract, and any
extension(s) thereof.
Part II: Disclosure
Following is the required disclosure of all contributions made from October 15, 2004, through the date of signing of this
Certification and Disclosure to: (i) any entity designated and organized as a “political organization” under 26 U.S.C.A. §
527 that is also defined as “continuing political committee” under N.J.S.A. 19:44A-3(n) and N.J.A.C. 19:25-1 or (ii) any
candidate committee and/or election fund of any candidate for or current holder of the public office of Governor; and any
State or county political party committee. Such an entity is identified in the following chart as a “Committee.”
DPP c51 - C&D, Rev. 10-23-2008
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