T0586 17DPP00152 Ownership Disclosure Form.pdf

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. 6.19.17 Page 1 of 2

OWNERSHIP DISCLOSURE FORM

BID SOLICITATION #: VENDOR/BIDDER:

PART 1

PLEASE COMPLETE THE QUESTIONS BELOW BY CHECKING EITHER THE “YES” OR THE “NO” BOX. ALL PARTIES ENTERING INTO A

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

YES NO

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

IF THE ANSWER TO QUESTION 1 IS “NO”, PLEASE SIGN AND DATE THE 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 PROVDE THE REQUESTED INFORMATION IN PART 2 BELOW.

PART 2

PLEASE PROVIDE FURTHER INFORMATION RELATED TO QUESTIONS 2 – 4 ANSWERED AS “YES”.

If you answered “YES” for questions 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.

INDIVIDUALS

NAME DATE OF BIRTH

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

NAME DATE OF BIRTH

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

NAME DATE OF BIRTH

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

Attach Additional Sheets If Necessary.

PART 2 continued

PARTNERSHIPS/CORPORATIONS/LIMITED LIABILITY COMPANIES

ENTITY NAME

PARTNER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

ENTITY NAME

PARTNER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

ENTITY NAME

PARTNER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

ENTITY NAME

PARTNER NAME

ADDRESS 1

ADDRESS 2

CITY STATE ZIP

Attach Additional Sheets If Necessary.

In the alternative, to comply with the ownership disclosure requirement, a Vendor/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% 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 percent or greater beneficial interest. N.J.S.A. 52:25-24.2.

CERTIFICATION

I, the undersigned, certify that I am authorized to execute this certification on behalf of the Vendor/Bidder, that the foregoing information and any attachments hereto, 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 that the Vendor/Bidder is under a continuing obligation from the date of this certification through the completion of any contract(s) 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. If I do so, I will be subject to criminal prosecution under the law, and 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.

Signature (Do not enter vendor ID as a signature) Date

Print Name and Title

FEIN/SSN