3-Stockholder Disclosure Certification.pdf

OWNERSHIP DISCLOSURE FORM

STATE OF NEW JERSEY

DEPARTMENT OF THE TREASURY - DIVISION OF PURCHASE AND PROPERTY

33 WEST STATE STREET, P.O. BOX 230 TRENTON, NEW JERSEY 08625-0230

DPP Rev. 9.21.2022

VENDOR NAME:

PURSUANT TO N.J.S.A. 52:25-24.2, ALL PARTIES ENTERING INTO A CONTRACT WITH THE STATE ARE REQUIRED TO PROVIDE A STATEMENT OF OWNERSHIP.

Please answer all questions and complete the information requested.

YES NO

1. The vendor is a Non-Profit Entity; and therefore, no disclosure is necessary.

2. The vendor is a Sole Proprietor; and therefore, no other disclosure is necessary.

A Sole Proprietor is a person who owns an unincorporated business by himself or her-self.

A limited liability company with a single member is not a Sole Proprietor.

3. The vendor is a corporation, partnership, or limited liability company with individuals, partners, members, stockholders, corporations, partnerships, or limited liability companies owning a 10% or greater interest; and therefore, disclosure is necessary.

If you answered YES to Question 3, you must disclose the information requested in the space below:*

(a) the names and addresses of all stockholders in the corporation who own 10% or more of its stock, of any class;

(b) all individual partners in the partnership who own a 10% or greater interest therein; or,

(c) all members in the limited liability company who own a 10% or greater interest therein.

NAME

ADDRESS

CITY STATE ZIP

YES NO

4. For each of the corporations, partnerships, or limited liability companies identified in response to Question #3 above, are there any individuals, partners, members, stockholders, corporations, partnerships, or limited liability companies owning a 10% or greater interest of those listed business entities?

If you answered YES to Question 4, you must disclose the information requested in the space below:*

(a) the names and addresses of all stockholders in the corporation who own 10% or more of its stock, of any class;

(b) all individual partners in the partnership who own a 10% or greater interest therein; or,

(c) all members in the limited liability company who own a 10% or greater interest therein. The disclosure(s) shall be continued until the names and addresses of every non-corporate stockholder, individual partner, and/or member a 10% or greater interest has been identified.

5. As an alternative to completing this form, a Vendor 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% 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% 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% or greater beneficial interest.*

* Attach additional sheets if necessary