164-22 Exhibits to Agreement for Workers Compensation Third Party Administration - 2022.pdf

Political Contribution Disclosure Statement Pursuant to Chapter 2, Section 68 of the Revised General Ordinances of the Township of West Orange Pursuant to Section 2-68.1 of the Revised General Ordinances of the Township of West Orange, please set forth below all political contributions in cash or in kind of two hundred ($200.00) dollars or more made within five (5) years of the date of acceptance of a proposal for a negotiated contract with the Township of West Orange, or within five (5) years of the notice of award for a bid contract with the Township of West Orange, either directly or indirectly, by the individuals or any of the principals of the business entity completing this form or by the business entity itself, to any elected official of the Township of West Orange currently in office or any political organization affiliated with an elected official of the Township currently in office.t If you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please X the line to the right. — | hereby certify under penalty of perjury that the information provided herein is true and accurate to the best of my knowledge, information and belief. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Council Woman Cindy Matute-Brown, Councilman Bill Rutherford; Councilwoman Susan McCartney, Councilwoman Michelle Casalino; and Councilwoman Tammy Williams. Company Name Authorized Signature Printed Name Date