295-24 Exhibit.pdf

C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM Required Pursuant To N.J.S.A. 19:44A-20,26 : This form or its permitted facsimile must be submitted to the local unit H no later than 10 days prior to the award of the contract. Part I - Vendor Information Vendor Name: | Address: | City: | | State: l Zip: The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this form. Signature Printed Name Title Part Il — Contribution Disclosure : Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contributions (more than $200 per election cycle) over the 12 months prior to submission to the ' committees of the government entities listed on the form provided by the local unit. CD Check here if disclosure is provided in electronic form. Contributor Name Recipient Name Date Dollar Amount $