35-22 Exhibit A - Extension of Agreement for Affordable Housing Administrative Services with CGPH - 2022.pdf

STOCKHOLDER DISCLOSURE CERTIFICATION Name of Business: I certify that the list below contains the names and home addresses of all Stockholders, Partners, or Sole Proprietor holding 10% or more of the issued and outstanding stock of the undersigned.* OR I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. * IMPORTANT NOTICE TO BIDDERS SEE NEXT PAGE Check the box that represents the type of business organization: Corp. Sign and notarize the form below, and, if necessary, complete the stockholder list below. Stockholders, Partners, or Sole Proprietor: Name: Name: Home Address: Home Address: Name: Name: Home Address: Home Address: Name: Name: Home Address: Home Address: Subscribed and sworn before me this ___ day of _________________________________ ___________, 2 __. (Affiant) (Notary Public) ________________________________ (Print name & title of affiant) My Commission expires: [CONTINUED ON NEXT PAGE] 10