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Resolutions - Jersey City

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C. 271 POLICAL CONTRUTION DISCLOSURE FORM<br />

Requied Pursuant To NJ.S.A. 19:44A.2026<br />

Part 1- Vendor Information<br />

Thi form or its permitted facsimile must be s~bmitted to the local unit<br />

no. later than i 0 da s dar to the award of the contract.<br />

rtïJ0j; ~r- t¥~:m..<br />

~ _ ~ ~ fSta:_ï: I Zi: õ5iøc<br />

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. Th~ underigned being authorzed to cerfy, hereby ceres tht the sumission provid~ htrejn repesents<br />

compliace with th provisi os ofNJ.S.A. 19:44A.20.26 and as resented by the Inctons accpanying this<br />

Part II - Contribution Disclosure<br />

. lólAO IY hi2AuHì.<br />

Prited Name . Title .'<br />

Disclosur requirement: Pursuat to'N.J.S.A.19:44A-20.26.ths disclosure must include allreportable<br />

politica çontrbutions (more than $300 per election cycle) over the 12 months prior to submission to the<br />

commttees of the goverent entities listed on tb Conn provided by the localunt.<br />

o Check here if disclosUre is provided in electronic for.<br />

o Check here if<br />

Contributor Name Rec(olenl Name Date ooirar Amount<br />

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1\ I Å A ( 'L<br />

1\/ V I V L ~ .<br />

the information is continued on subsequent page(s)<br />

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. .<br />

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