141-25 Exhibit.pdf

STATEMENT OF OWNERSHIP DISCLOSURE NLS.A, 52:25-24.2 (P.L. 1977, c.33, as amended by P.L. 2016, c.43) ‘This statement shall be completed, certified to, and included with all bid and proposal submissions. Failare to'submit the required information is cause for automatic rejection of the bid or proposal, Name of Organization: Organization Address: Part I Check the box that represents the type of business organization: Dsote Proprietorship {skip Parts tl and III, execute certification in Part IV) Oo Non-Profit Corporation (skip Parts Il and Ill, execute certification in Part IV) oO For-Profit Corporation {any type) DDhimites Liability Company {LLC) oO Partnership ol Limited Partnership GAhinites Liability Partnership (LLP) | Other (be specific): Part oO The list below contains the names and addresses of all stockholders in the corporation who own 16 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 @ 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 stack, of any class, of no individual partner in the. partnershig owns a 10 percent or greater interest therein, or no member in the limited liability company owns 2 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 Page | 20 Le ine |