110013_StandardDocumentsV7.pdf

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Page of R 1/31/2011 (Date) (Title) (Name) (Signature) Certification: I, being duly sworn upon my oath, hereby represent and state that the foregoing information and any attachments thereto to the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying on the information contained herein and thereby acknowledge that I am under a continuing obligation from the date of this certification through the completion of any contracts with the State to notify the State in writing of any changes to the answers of information contained herein. I acknowledge that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if I do so, I recognize that I am subject to criminal prosecution under the law and that it will also constitute a material breach of my agreement(s) with the State of New Jersey and that the State at its option may declare any contract(s) resulting from this certification void and unenforceable.I certify that the signature on this page has the effect of and constitutes a signature on every page.

This certification will serve as your official signature for the following forms presented within this document packet.1. Ownership Disclosure Form2. Disclosure of Investigations and Actions Involving Bidder Form State of New JerseyDivision of Purchase and PropertyStandard Forms Certification State of New JerseyDivision of Purchase and PropertyOwnership Disclosure Form INSTRUCTIONS: Provide below the names, home addresses, dates of birth, and ownership interest of all individuals, and any partnerships, corporations and any other owner having a 10% or greater interest in the firm named above. If a listed owner is a corporation or partnership, provide below the same information for the holders of 10% or more interest in the corporation or partnership. If this form has previously been submitted to the Purchase Bureau in connection with another bid, indicate changes, if any, where appropriate, and complete the certification below.Include the name, home address, and date of birth, of all officers of the bidder/offeror named above. If an officer has no ownership interest, so indicate with a zero.

Complete All Questions Below

1. Within the past five years has another company or corporation had a 10% or greater interest in the firm identified above? (If yes, complete and attach a separate disclosure form reflecting previous ownership interests.)

YES NO

2. Has any person or entity listed in this form or its attachments ever been arrested, charged, indicted or convicted in a criminal or disorderly persons matter by the State of New Jersey, any other State or the U.S. Government? (If yes, attach a detailed explanation for each instance.)

3. Has any person or entity listed in this form or its attachments ever been suspended, debarred or otherwise declared ineligible by any agency of government from bidding or contracting to provide services, labor, material, or supplies? (If yes, attach a detailed explanation for each instance.)

4. Are there now any criminal matters or debarment proceedings pending in which the firm and/or its officers and/or managers are involved? (If yes, attach a detailed explanation for each instance.)

5. Has any Federal, State or Local license, permit or other similar authorization, necessary to perform the work applied for herein and held or applied for by any person or entity listed in this form, been suspended or revoked, or been subject or any pending proceedings specifically seeking or litigating the issue of suspension or revocation? (If yes, attach a detailed explanation for each instance.)

Officer State of New JerseyDivision of Purchase and PropertyDisclosure of Investigations and Actions Involving Bidder Investigation:

Indicate "NONE" in the "Person or Entity" field if no investigations were undertaken.

The bidder shall provide a detailed description of any investigation, litigation, including administrative complaints or other administrative proceedings, involving any public sector clients during the past five years including the nature and status of the investigation, and, for any litigation, the caption of the action, a brief description of the action, the date of inception, current status,and, if applicable, disposition.

Litigation/Administrative Compaints:

Indicate "NONE" in the "Person or Entity" field if no Litigation/Administrative Complaints.

Additional Ownership information