Common use of Iran Divestment Act Compliance Clause in Contracts

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000027 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Xitle Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer :‌ SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000063 APT E-PIN #: See Footer Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000051 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency 000029 APT E-PIN #: See Footer Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: 000028 APT E-PIN #: See Footer SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation Agency Address New York City New York State NY Zip Code 10041 Contact Person Xxxxxx Xxxxxx Title Director of M/WBE Program & Oversight Telephone # (000) 000-0000 Email xxxxxxxx@xxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4

Iran Divestment Act Compliance. PLEASE CHECK ONE: By submission of this Bid, I certify, and in the case of a joint Bid each party thereto certifies as to its own organization, under penalty of perjury, that to the best of my knowledge and belief, that the Bidder is not on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. OR I am unable to certify that my name and the Bidder does not appear on the list created pursuant to paragraph (b) of subdivision 3 of Section 165-a of the State Finance Law. I have attached a signed statement setting forth in detail why I cannot so certify. (Signature of Bidder) Print Name: Print Title: Subscribed and sworn to before me this day of , 20 Notary Public Tax ID #: APT E-PIN #: See Footer 81018B0002 THE CITY OF NEW YORK SCHEDULE B – M/WBE Utilization Plan Part I: M/WBE Participation Goals Part I to be completed by contracting agency Contract Overview APT E- Pin # See Footer 81018B0002 FMS Project ID#: See Contract Cover Page Project Title/ Agency PIN # See Footer Microfiche Storage, Retrieval, and Duplication Bid/Proposal Response Date See Article 1 Contracting Agency Department of Transportation DOB Agency Address New York City New York State NY 000 Xxxxxxxx Xxxx Xxx Xxxx Xxxxx XX Zip Code 10041 10007 Contact Person Xxxxxx Xxxxxx Xxxxx Xxxxxxxxx Title Director of M/WBE Program & Oversight Procurement Attorney Telephone # (000) -000-0000 Email xxxxxxxx@xxx.xxx.xxx xxxxxxxxxx@xxxxxxxxx.xxx.xxx Project Description (attach additional pages if necessary) See Article 4Storage, retrieval, and duplication as needed of the Department of Buildings microfiche records.