224-22 Exhibit B-RFQ Licensed Tree Expert for Township Tree Inventory.pdf

Page | 22 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. The current elected officials of the Township include the following: Mayor Robert D. Parisi; Councilwoman Susan McCartney; Councilwoman Cindy Matute Brown; Councilman Bill Rutherford; Councilwoman Tammy Williams; and Councilwoman Michelle Casalino. Name of Contributor Amount Recipient of Contribution Contribution Date ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ _______________ ________ ___________________ __________ ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ ________________ ________ ___________________ __________ If you have NOT made any contributions within the scope of Section 2-68.1, as set forth above, please indicate here ___________. I hereby certify under penalty of perjury that the information provided herein is true and accurate to the best of my knowledge, information and belief. Signature _________________________________________ Print Name:_________________________________________ Company:______________________________________________ ______________________________________________________