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Springfield Free Public Library/Township of Springfield BUSINESS ENTITY DISCLOSURE CERTIFICATION FOR NON -FAIR AND OPEN CONTRACTS Required Pursuant To N.J.S.A. 19:44A -20.8 SPRINGFIELD FREE PUBLIC LIBRARY, TOWNSHIP OF SPRINGFIELD Part I — Vendor Affirmation The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that the <name of business entity> has not made and will not make any reportable contributions pursuant to N.J.S.A. 19:44A -1 et seq. that, pursuant to P.L. 2004, c. 19 would bar the award of this contract in the one year period preceding on or about April 20, 2010 to any of the following named candidate committee, joint candidates committee; or political party committee representing the elected officials of the Township of Springfield as defined pursuant to N.J.S.A. 19:44A- 3 and (r). Ziad Shehady Jerry Fernandez Bart Fraenkel Marc Krauss Hugh Keffer Part II — Ownership Disclosure Certification ❑ I certify that the list below contains the names and home addresses of all owners holding 10% or more of the issued and outstanding stock of the undersigned. Check the box that represents the type of business entity: ❑Partnership ❑Corporation El Sole Proprietorship ❑Subchapter S Corporation ❑Limited Partnership ❑Limited Liability Corporation ❑Limited Liability Partnership Name of Stock or Shareholder I Home Address Part 3 — Signature and Attestation: The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and certification, I and/or the business entity, will be liable for any penalty permitted under law. Name of Business Entity: Signature of Affiant: Title: Printed Name of Affiant : Date: Subscribed and sworn before me this day of ,2 (Witnessed or attested by) My Commission expires: (Seal) C:%Program FileslNeevio.ComlDocument ConverterltemplPDFConvert .3395.1.Springfield Free ILS RFP March 2010. doc 15 Attachment number 2 F -12 Page 174