Township Council Meeting — Packet

Section B (skip if no business entities are listed in Section A of Part IV) Below are the names and addresses of any entities in which an entity listed in oO Part Ill A owns greater than 50 percent of the voting stock (corporation) or owns greater than SO percent interest (partnership or limited liability company). Name of Business Entity Controlled by Entity Physical Address Listed in Section A of Part IV **Add additional Sheets if necessary** OR No entity listed in Part Ill A owns greater than 50 percent of the voting stock oO in any corporation or owns greater than 50 percent interest in any partnership or limited liability company. Section C — Part IV Certification | hereby certify that the Organization listed above in Part | does not own greater than 50 percent of any entity that that is debarred by the federal government from contracting with a federal agency and, if applicable, does not own greater than 50 percent of any entity that in turns owns greater than 50 percent of any entity debarred by the federal government from contracting with a federal agency. | further acknowledge: that | am authorized to execute this certification on behalf of the above-named organization; that the Township of West Orange is relying on the information contained herein and that | am under a continuing obligation from the date of this certification through the date of contract award by Township to notify the Township in writing of any changes to the information contained herein; that | am aware that it is a criminal offense to make a false statement or misrepresentation in this certification, and if | do so, |am subject to criminal prosecution under the law and that it will constitute a material breach of my agreement(s) with the Township permitting the Township to declare any contract(s) resulting from this certification void and unenforceable. Full Name (Print): Title: Signature: Date: P-52