1-Ownership Disclosure.pdf
PDF 107 KB Posted
- Solicitation number
- BC-RFQ-25-008.2
- Issued by
- Bergen County, New Jersey
About this file
The document is an Ownership Disclosure Certification form required for bid submissions, likely for a state or local government contract in New Jersey. The form is designed to provide transparency about business ownership by requiring bidders to disclose stockholders holding 10% or more of the company's issued and outstanding stock. If the bidding entity has a publicly traded parent company, the form allows for alternative disclosure methods, such as providing the website and page numbers of the last annual SEC filing.
The form provides options for different types of business organizations, including Partnership, Corporation, Sole Proprietorship, Limited Partnership, Limited Liability Corporation, Limited Liability Partnership, and Subchapter S Corporation. Bidders must either list the names and home addresses of stockholders meeting the 10% ownership threshold or certify that no stockholder owns 10% or more of the company's stock. The form includes spaces for multiple stockholder entries and requires the signature of an authorized representative (affiant) who will print their name and title.
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Text version
OWNERSHIP DISCLOSURE CERTIFICATION
This Statement Shall Be Included with Bid Submission (Use Additional Sheets as Necessary)
Name of Business______________________________________________________
I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. However if a parent entity holding 10% or more is a publicly traded entity, then the respondent in complying with N.J.S.A. 52:25-24.2 may submit the name and address of each publicly traded entity, and the name and address of each person holding 10% or more beneficial interest in the publicly traded entity as of the last the last annual filling with the Security Exchange Commission (SEC), or foreign equivalent.
OR
I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned.
Check the box that represents the type of business organization:
Partnership Corporation Sole Proprietorship
Limited Partnership Limited Liability Corporation Limited Liability Partnership
Subchapter S Corporation Other, Please List_______________
Sign the form below, and, if necessary, complete the stockholder list below. Stockholders:
Name: ______________________________ Name: ______________________________
Home Address: _______________________
Home Address: _______________________
Name: ______________________________ Name: ______________________________
Home Address: _______________________
Home Address: _______________________
Publicly Traded Parent Company Disclosure:
Submit the Website (URL) providing the last annual SEC, or foreign equivalent filing:
Please list the applicable page number(s) of the SEC or foreign equivalent filing:
(Affiant)
(Print name & title of affiant)
| I certify that the list below contains the names and home addresses of all stockholders holding 10 or: Off |
| I certify that no one stockholder owns 10 or more of the issued and outstanding stock of the: Off |
| Partnership: Off |
| Limited Partnership: Off |
| Subchapter S Corporation: Off |
| Corporation: Off |
| Limited Liability Corporation: Off |
| Other Please List: Off |
| Sole Proprietorship: Off |
| Limited Liability Partnership: Off |
| undefined: |
| Name: |
| Name_2: |
| Home Address: |
| Home Address_2: |
| undefined_2: |
| undefined_3: |
| Name_3: |
| Name_4: |
| Home Address_3: |
| Home Address_4: |
| undefined_4: |
| undefined_5: |
| Print name title of affiant: |
| Name of Business: |
| URL of Annual SEC Filing: |
| Page Numbers: |
| Signature: |
File details come from the government source that posted it. Updated .