CONTRACTOR'S STATEMENT FOR PUBLIC DISCLOSURE *

1. a/ Name of Contractor:

b/ Address and Zip Code of Contractor:

2. If the Contractor is not an individual doing business under his own name, the Contractor has the status indicated below and is organized or operating under the laws of _________:

_____ a corporation

_____ a partnership known as:

_____ a business association or a joint venture known as:

_____ a Federal, State or Local government or instrumentality thereof

_____ other (explain)

3. If the Contractor is not an individual or a government agency or instrumentality, give date of organization:_____________________________

4. Names, addresses, title of position (if any), and nature and extent of the interest of the officers and principal members, shareholders, investors other than a government agency or instrumentality, are set forth as follows:

a/ If the Contractor is a corporation, the officers, directors, trustees, and each stockholder owning more than 10% of any share of stock.

b/ If the Contractor is a partnership, each partner, whether a general or limited partner, and either the percent of interest or a description of the character and extent of interest.

c/ If the Contractor is a business association or a joint venture, each participant and either the percent of interest or a description of the character and extent of interest.

d/ If the Contractor is some other entity, the officers, the members of the governing body, and each person having an interest of more than 10%.

* If space on this form is inadequate for any requested information, this should be furnished on an attached page which is referred to under the appropriate numbered item on the form.

Contractor's Statement for Public Disclosure

POSITION TITLE (if any) AND PERCENT

OF INTEREST OR DESCRIPTION OF

NAME, ADDRESS & ZIP CODE CHARACTER AND EXTENT OF INTEREST

5. Name, address and nature and extent of interest of each person or entity (not named in response to

Item 4) who has a beneficial interest in any of the shareholders or investors named in response to Item 5 which gives such person or entity more than a computed 10% interest in the Contractor (for example, more than 20% of the stock in a corporation which holds 50% of the stock of the Contractor, or more than 50% of the stock in a corporation which holds 20% of the stock of the Contractor).

DESCRIPTION OF CHARACTER

NAME, ADDRESS & ZIP CODE AND EXTENT OF INTEREST

6. Names (if not given above) of officers and directors or trustees of any corporation or firm listed under

Item 4 or Item 5 above:

7. Is the Contractor a subsidiary of or affiliated with any other corporation or any other firm or firms?

___ YES ___ NO. If yes, list each such corporation or firm by name and address, specify its relationship to the Contractor, and identify the officers and directors or trustees common to the Contractor and such other corporation or firm:

8. Other federal grant projects under Title I of the Housing and Community Development Act of 1974

(CP.L.93-383), as amended, in which the Contractor or any of the principals of the Contractor is or has been the contractor, or a stock-holder, officer, director or trustee, or partner of such a contractor:

9. If the Contractor or a parent corporation, a subsidiary, an affiliate or a principal of the Contractor is to participate in the work or services as a Subcontractor or consultant:

a/ Name and address of such Subcontractor or consultant:

b/ Has such Subcontractor within the last 10 years ever failed to qualify as a responsible bidder, refused to enter into a contract after an award has been made, or failed to complete a contract?

___YES ___ NO. If yes, explain:

Contractor's Statement for Public Disclosure c/ Outstanding contract bids of such Subcontractor or consultant:

Awarding Agency Amount Date Opened

10. Brief statement respecting equipment, experience, financial capacity, and other resources available to such Subcontractor or consultant for the performance of the work or services involved in the contract, specifying particularly the qualifications of the personnel, the nature of the equipment, and the general experience of the Subcontractor or consultant.

11. a/ Does any member of the governing body or employee of the Local Public Agency or any officer or employee of the Local Public Agency who exercises any functions or responsibilities in connection with the awarding and/or carrying out of the contract have any direct or indirect personal interest in the Contractor or in the Contractor's performance under the contract? ___YES ___NO. If yes, explain:

b/ Does any member of the governing body of the locality in which the Public Improvement

Project is situated or any other public official of the locality, who exercises any functions or responsibilities in the review or approval of the awarding and/or carrying out of the contract have any direct or indirect personal interest in the Contractor or in the Contractor's performance under the contract? ___YES ___NO. If yes, explain:

CERTIFICATION

I (We) ______________________________________________________________ certify that this Contractor's Statement for Public Disclosure is true and correct to the best of my (our) knowledge and beliefs.

DATED: ___________________ DATED: __________________

(SIGNATURE) (SIGNATURE)

(TITLE) (TITLE)

(ADDRESS & ZIP CODE) (ADDRESS & ZIP CODE)

1 - If the Contractor is an individual, this Statement should be signed by such individual; if a partnership, by one of the partners; if a corporation or other entity, by one of its chief officers having knowledge of the facts required by this Statement.

2 - Penalty For False Certification: Section 1001, Title 18, of the U.S.C. provides a fine of not more than $10,000, or imprisonment of not more than five years, or both, for knowingly and willfully making or using any false writing or document, knowing the same to contain any false, fictitious or fraudulent statement or entry in a matter within the jurisdiction of any Department of the United States.

(ONLY AS NEEDED)

CERTIFICATE OF ACKNOWLEDGMENT OF RECEIPT OF ADDENDUM

THE CITY OF READING

ADDENDUM NO. _______________ TO BID FOR: _________________________________

OPENING DATE:__________________

NOTICE

This addendum must be signed, attached to, and returned with your proposal to the City of Reading by the time and date indicated above. This sheet is now part of the Contract Documents.

I, HEREBY CERTIFY, THAT THE CHANGES COVERED BY THIS ADDENDUM HAVE BEEN TAKEN INTO

ACCOUNT WITH THE TOTAL BID PRICE.

Firm Name (Type or Print)_______________________________________

Authorized Signature _____________________Title__________________

Name (Type or Print)_____________________Date___________________