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c. 271" POLmCAL CONTllUnON DISLOSURE fORM
Required Pursuat To N_J.S.A. i 9:44A-20.26
This form or its permìtted facsimile must be submitted to the local unit
the contrct.
no later tban 10 days pnor to the award of
fu~. '
The undersiged bcig authorize to cerify, herby ceifies that the submission provided herein
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reprents
compliance with the provisions ofN.l.S.A. 19:44A-20.26 and as reprsented by the Instrctions accmpaning this
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Signature
Part II - Contributon Disclosure,
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PnntedName
1/l.c/r;¡
Title
Disclosur requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportble.
political contrbutions (more than $300 per election cycle) over the 12 months prior to submission to the
commttees of the governent entities listed on the form provided by the local unt.
o Check here if disclosure is provided in electrnic fonn-
o Check
Contributor Name
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here îfthe infonnation is continued on subsequent page(s)
Recipient Name Date Dollar Amount
$