1-Ownership Disclosure.pdf
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- Solicitation number
- BC-RFQ-26-006
- Issued by
- Bergen County, New Jersey
About this file
This is an Ownership Disclosure Certification form required as part of a bid submission for a New Jersey county's Request for Qualifications (RFQ BC-RFQ-26-006) for Licensed Site Remediation Professional services. The certification must be completed and submitted with all bids and requires respondents to disclose all stockholders holding 10% or more of issued and outstanding stock. Alternatively, if the respondent is owned by a publicly traded entity holding 10% or more, the bidder may submit the name and address of the publicly traded parent company and identify individuals holding 10% or more beneficial interest as reported in the most recent SEC filing or foreign equivalent. The form requires respondents to identify their business organization type, including options for partnership, corporation, sole proprietorship, limited partnership, limited liability corporation, limited liability partnership, or Subchapter S corporation.
The disclosure form must be signed and notarized by an authorized representative of the bidding company. Respondents with no individual stockholder holding 10% or more of outstanding stock must certify this fact on the form. For publicly traded parent companies, respondents must provide the website URL and applicable page numbers of the last annual SEC or equivalent foreign filing supporting the ownership disclosure. This certification ensures transparency regarding business ownership and control as part of the county's procurement process for Licensed Site Remediation Professional services for a 12-month contract period commencing on the date of award.
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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: |
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