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

Part 4: CertificationI have read the instructions accompanying this form prior to completing this certification on behalf ofthe above-named business entity.I certfy that, to the best of my knowledge f'nd belief, the foregoing statements by me are true. I arT aware that if any of the statements,are wilfully false, I am subject to punishment.I understand that this certifcation wil be in effect for two (2) years from the dateof approval, provided the ownership statusdoes not change and/or additional contributions are not made. If there are any changesin the ownership ofthe entity or additionalcontributions are made, a new full set of ç10cuments i:re required to be completed and submitted. By submitting this Certifcation andDisclosure, the person or entitynamed herein acknowledges this continuing rep"orting responsibilty and certfies that it wil adherè to it.(CHECKONE BOX A, B or C)_:~ ~: (A) 0 I a~òertitying on be~alfofthei:bove-nam~d business entity ~nd all individuals and/or entities whose eontributiònsareattributable to the entit pursuant to Executive Order117 (2008). _ '(B) 0 I am certifying on behalf of the ~bove-named business entity only,(C) 0 I am certifying on behalf of an individual and/or entity whose contributionsare attributable to the vendor.Signed Name tvtUi-Phone Number (617) 668-6904~~.~Prirn Nam.DateMark CaldwellJU19,2009Title/PositionGeneral ManagerAgency Submission of Forms'The agency should ,submit the completèd and signed Two-Year Vèndor "Certification and Disclosure forms, together with acompleted Ownership Disclosure form, eitherèlectronically to cd134(gtreas.state.nj.us, or regular mail at Ghapter 51 ReviewUnit, P.O. Box 039,33 West State Street, '9th Floor, Trenton, NJ 08625. The agency should save the formsoriginal forms on fie~ ~_nd submit copies to- ~.,-~ . ~ . . the .. .~. Chapter . 51 Review Unit., , _".'c "'-~,Joèally and k~~p theCHSL.l Rl/;21/2009 Page 3 of 3