Fillable OWNERSHIP DISCLOSURE FORM (New Jersey Schools Development Authority)

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OWNERSHIP DISCLOSURE FORM (New Jersey Schools Development Authority)

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STATE OF NEW JERSEY
DEPARTMENT OF THE TREASURY
DIVISION OF PURCHASE AND PROPERTY
33 WEST STATE STREET, P.O. BOX 230
TRENTON, NEW JERSEY 08625-0230
DPP Rev. 9.24.19 Page 1 of 2
OWNERSHIP DISCLOSURE FORM
BID SOLICITATION #:
VENDOR {BIDDER}:
ALL PARTIES ENTERING INTO A CONTRACT WITH THE STATE ARE REQUIRED TO PROVIDE THE
INFORMATION REQUESTED PURSUANT TO N.J.S.A. 52:25-24.2.
PLEASE NOTE THAT IF THE VENDOR/BIDDER IS A NON-PROFIT ENTITY, THIS FORM IS NOT REQUIRED.
PART 1
YES
NO
Are there any individuals, partners, members, stockholders, corporations, partnerships, or limited
liability companies owning a 10% or greater interest in the Vendor {Bidder}?
If you answered, “YES” above, you must disclose the following: (a) the names and addresses of all stockholders in the corporation
who own 10 percent or more of its stock, of any class; (b) all individual partners in the partnership who own a 10 percent or
greater interest therein; or, (c) all members in the limited liability company who own a 10 percent or greater interest therein.
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
Attach Additional Sheets If Necessary.
Page 2 of 2
PART 2
YES
NO
Of those entities disclosed above owning a 10% or greater interest in the Vendor {Bidder}, are
there any individuals, partners, members, stockholders, corporations, partnerships, or limited
liability companies owning a 10% or greater interest of those listed entities?
If you answered, “YES” above, you must disclose the following: (a) the names and addresses of all stockholders in the corporation
who own 10 percent or more of its stock, of any class; (b) all individual partners in the partnership who own a 10 percent or
greater interest therein; or, (c) all members in the limited liability company who own a 10 percent or greater interest therein.
Please note that this disclosure shall be continued until names and addresses of every non-corporate stockholder, and individual
partner, and member, exceeding the 10 percent ownership criteria established in this act, has been identified.
Name of the entity listed above to which the disclosure below applies:
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
NAME
ADDRESS 1
ADDRESS 2
CITY
ZIP
Attach Additional Sheets If Necessary.
PART 3
As an alternative to completing this form, a Vendor {Bidder} with any direct or indirect parent entity which is publicly traded may
submit the name and address of each publicly traded entity and the name and address of each person that holds a 10 percent or
greater beneficial interest in the publicly traded entity as of the last annual filing with the federal Securities and Exchange Commission
or the foreign equivalent, and, if there is any person that holds a 10 percent or greater beneficial interest, also shall submit links to
the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and
the relevant page numbers of the filings that contain the information on each person that holds a 10 percent or greater beneficial
interest.
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Completed 21 July 2020

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