Resolution of the City of Jersey City, N.J.

, C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORMRequired Pursuant To N.ISA. 19:44A-20.26This form or its permitted facsimile must be submitted to the local unit 'no later than 10 days prior to the award of the contract.. '¡:-~Part I - Vendor InformationVendor Name: I RM'Instuinents CorpAddress: I 44.Hunt Street,City: T Watertown.. ;I State: MA I, Zip: 02472,...fonn. ' '", 'compliance with the provisions ofN_J.S.A. 19:44A-20.26 and asThe undersigned being authorized to certify, hereby cei1ifies that the submission provided herein representsrepresented by the Instructions accompanying this')U/t 1 fld O.Utve: r Outltvt4-kSignature , , ( Printed Name , . TitlePart II:. ContributionDisclosure. Disclosure reqiiirement: Pursuant toN,IS.A.19:44A-20.26 tIus disclosure must incllide all reportablepolitical contributions (more thai $300 per election cycle) over tiie 12 months prior to submission to thecommittees of tiie government.entities listed on'thefonn provided by the local unt.o 'Check here ifdisclosure is providedii:i electronic fmID.,. Contributor Name Recipient Name Date Dollar Amount- -'... -, .~$-";0 .=.",,; , I n//\ l l)lLX-,-- / ''L--",,,,,,, ' ',,-, ,D , Check here if tle information is contiued on subsequent page( s)