111-24 Exhibit A.pdf

STATEMENT OF OWNERSHIP DISCLOSURE NJ.S.A. 52:25-24.2 (P.L. 1977, ¢.33, as amended by P.L. 2016, ¢.43) This statement shall be completed, certified to, and included with all bid and proposal submissions. Failure to submit the required information is cause for automatic rejection of the bid or proposal. Name of Organization: Nationwide Cleaning & Restoration Services Same of rg: ao Organization Address: _ 101 Hudson st, 21st Fl, Jersey City, NJ 07302 Part I Check the box that represents the type of business organization: Oscie Proprietorship (skip Parts II and III, execute certification in Part IV) non-profit Corporation (skip Parts II and III, execute certification in Part [V) Bar or-Profit Corporation (any type) oO Limited Liability Company (LLC) oO Partnership oO Limited Partnership oO Limited Liability Partnership (LLP) Dotner (be specific): Part Il | The list below contains the names and addresses of all stockholders in the corporation who own 10 percent or more of its stock, of any class, or of all individual partners in the partnership who own a 10 percent or greater interest therein, or of all members in the limited liability company who own a 10 percent or greater interest therein, as the case may be. (COMPLETE THE LIST BELOW IN THIS SECTION) OR oO No one stockholder in the corporation owns 10 percent or more of its stock, of any class, or no individual partner in the partnership owns a 10 percent or greater interest therein, or no member in the limited liability company owns a 10 percent or greater interest therein, as the case may be. (SKIP TO PART IV) (Please attach additional sheets if more space is needed): Name of Individual or Business Entity ] Address Dayana Badran Salvador Carmelo PT