141-25 Exhibit.pdf

i i { t Ic: ion Disclosure Statement Pursuant to Ch lon 68. 1 Revise General Ordinances of the Township of West Orango Pursuant to Section 2-68.1 of the Revised General Ordinances of the Township of West Orange, please set farth below ail political contributions in cash or in kind of two hundred ($209.00), dollars or more made within five (6) 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, elther directly or indirectly, by the individuals or any of the principals of the business antily completing this form or hy the business entity itself, to any elected official of the Township of West Orange currently in office or any political organization affiflated with an elected official of the Township currently in office,’ Ifyou have NOT made any contributions within the scope of Section 2-58.1, 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 knowledga, Information and belief. ‘The current elected officials of the Township include the following: Mayor Susan McCartney, Councilman Bill Rutherford, Counciwoman Michelle Casalino, Councilwoman Tammy Williams, Councilwoman Asmeret Ghebremicae! and Councilwoman Susan Scarpa . Company Name Authorized Signature Printed Name Date rage [25 —. en ee