1-Ownership Disclosure.pdf

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Attached to
Real Estate Appraiser, to Provide “Review Appraisal” Services on an “As Needed” Basis for the Bergen County Department of Parks, Division of Land Management for the 2026 Calendar Year
Solicitation number
BC-RFQ-26-004
Issued by
Bergen County, New Jersey

About this file

Written by GovTribe AI ·

This document is an Ownership Disclosure Certification form required for bid submissions, likely for a state or local government procurement process in New Jersey. The form requires businesses to disclose stockholders who own 10% or more of the company's issued and outstanding stock, with alternative reporting options for publicly traded parent companies. Bidders must indicate their business organization type (such as corporation, partnership, LLC) and provide detailed stockholder information including names and home addresses.

The form is designed to ensure transparency in business ownership for government contract bidding, specifically complying with New Jersey Statute N.J.S.A. 52:25-24.2. Businesses must either list stockholders meeting the 10% ownership threshold or certify that no stockholder owns 10% or more of the company's stock. For publicly traded entities, the form allows submission of the parent company's SEC filing information as an alternative disclosure method. The document provides space for listing multiple stockholders and requires the signature of an authorized representative (affiant) to certify the accuracy of the ownership information provided.

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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 .