17_03_20 - Ownership Disclosure.pdf

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STATE OF NEW JERSEY -- DIVISION OF PURCHASE AND PROPERTY

OWNERSHIP DISCLOSURE FORM

PART 1: PLEASE COMPLETE THE QUESTIONS BELOW BY CHECKING EITHER THE "YES" OR "NO" BOX.

ALL PARTIES ENTERING INTO A CONTRACT WITH THE STATE ARE REQUIRED TO COMPLETE THIS FORM PURSUANT TO N.J.S.A. 52:25-24.2PLEASE NOTE: IF THE VENDOR BIDDER IS A NON-PROFIT, THIS FORM IS NOT REQUIRED.

PLEASE COMPLETE THE SEPARATE DISCLOSURE OF INVESTIGATIONS FORM.

1. Are there any individuals, corporations, partnerships, or limited liability companies owning a 10% or greater interest in the Vendor Bidder?

YES

NO

IF THE ANSWER TO QUESTION 1 IS NO, PLEASE SIGN AND DATE THE FORM.

YOU DO NOT HAVE TO COMPLETE ANY MORE QUESTIONS ON THIS FORM.

IF THE ANSWER TO QUESTION 1 IS YES, PLEASE ANSWER QUESTIONS 2-4 BELOW.

2. Of those parties owning a 10% or greater interest in the Vendor Bidder, are any of those parties individuals?

3. Of those parties owning a 10% or greater interest in the Vendor Bidder, are any of those parties corporations, partnerships, or limited liability companies?

4. If your answer to Question 3 is “YES”, are there any parties owning a 10% or greater interest in the corporation, partnership or limited liability company referenced in Question 3?

IF ANY OF THE ANSWERS TO QUESTIONS 2-4 ARE YES, PLEASE PROVIDE THE REQUESTED INFORMATION IN PART 2 BELOW.

If you answered "YES" for question 2, 3 or 4, you must disclose identifying information related to the individuals,corporations, partnerships, and/or limited liability companies owning a 10% or greater interest in the Vendor Bidder. Further, if one or more of these entities is itself a corporation, partnership, or limited liability company, you must also disclose all parties that own a 10% or greater interest in that corporation, partnership, or limited liability company. This information is required by statute.

TO COMPLETE PART 2, PLEASE PROVIDE THE REQUESTED INFORMATION PERTAINING TO EITHER INDIVIDUALS, CORPORATIONS, PARTNERSHIPS, OR LIMITED LIABILITY COMPANIES HAVING A 10% OR GREATER INTEREST IN THE VENDOR BIDDER. IF YOU NEED TO MAKE ADDITIONAL ENTRIES, CLICK THE “ADD AN ENTRY” BUTTON IN THE APPROPRIATE ENTITY BOX.

PART 2: PLEASE PROVIDE FURTHER INFORMATION RELATED TO QUESTIONS 2-4 ANSWERED AS "YES".

Individuals Are there additional entities holding a 10% or greater ownership interest in the Vendor Bidder and its parent corporation, partnership or limited liability company?

or Partnerships/Corporations/Limited Liability Companies Are there additional entities holding a 10% or greater ownership interest in the Vendor Bidder and its parent corporation, partnership or limited liability company?

or In the alternative, to comply with this section, a bidder with any direct or indirect parent entity which is publicly traded may submit the name and address of each publicly traded entity and the name and address of each person that holds a 10 percent or greater beneficial interest in the publicly traded entity as of the last annual filing with the federal Securities and Exchange Commission or the foreign equivalent, and, if there is any person that holds a 10 percent or greater beneficial interest, also shall submit links to the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and the relevant page numbers of the filings that contain the information on each person that holds a 10 percent or greater beneficial interest. N.J.S.A. 52:25-24.2

Certification: I hereby certify that the foregoing information and any attachments hereto, to the best of my knowledge are true and complete. I certify that I am authorized to execute this form on behalf of the Vendor Bidder; and acknowledge that the State of New Jersey is relying on the information contained herein and that the Vendor Bidder is 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 information contained herein; 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 am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the State, permitting the State to declare any contract(s) resulting from this certification void and unenforceable.

Do Not Enter Vendor ID as a Signature