1-Ownership Disclosure.pdf

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)