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Springfield Free Public Library /Township of Springfield <br />4 STOCKHOLDER DISCLOSURE CERTIFICATION <br />This Statement Shall Be Included with Bid Submission <br />Name of Business <br />[ I certify that the list below contains the names and home addresses of all stockholders <br />holding 10% or more of the issued and outstanding stock of the undersigned. <br />OR <br />[ I certify that no one stockholder owns 10% or more of the issued and outstanding stock of <br />the undersigned. <br />Check the box that represents the type of business organization: <br />[ Partnership <br />Limited Partnership <br />[ Subchapter S Corporation <br />[ Corporation <br />[Limited Liability Corporation <br />[ Sole Proprietorship <br />[Limited Liability Partnership <br />Sign and notarize the form below, and, if necessary, complete the stockholder list below. <br />Stockholders: <br />Name: <br />Home Address: <br />Name: <br />Home Address: <br />Name: <br />Home Address: <br />Name: <br />Home Address: <br />Name: <br />Home Address: <br />Name: <br />Home Address: <br />C:IProgram FileslNeevia.Corn0ocument ConverterltempWI )FConvert.3395. I. Springfield Free ILS RFP March <br />2010.doc 13 <br />Attachment number 2 <br />F -12 Page 172 <br />