A State officer or employee, or special State officer or employee, of a State agency as defined in N.J.S.A 52:34-10.11
who is involved in the procurement process must complete this form in full. Involvement in the procurement process
means drafting, reviewing, evaluating or making contract awards or substantively assisting in any of those tasks, or
authorizing payments under those contracts.
The completed form must be filed with the head of the State agency in which the State officer or employee, or special
State officer or employee, holds office or employment. A copy of the completed form must be forwarded to the State
Ethics Commission, PO Box 082, Trenton, NJ 08625-0082. (Hand delivery address: 28 West State Street, Room 1407,
Trenton, NJ 08608).
The completed form must be reviewed by the filer on an annual basis. A new form must be completed any time there is a
material change to any response.
1. Please specify below any interest you hold in any firm, association, partnership, corporation or other business
organization, including any subsidiary or related company thereof, that has sought or been awarded a public contract with
your agency or any agency with which you have involvement in the procurement process.
"Interest" means any ownership or control of any profits or assets of a business organization. Include both the name of
the business organization and the nature of your interest (number of shares held, percentage of partnership, etc.).