Business Entity Disclosure Certification

Vendor Affirmation

The undersigned, being authorized and knowledgeable of the circumstances, does hereby certify that the firm listed below has not made and will not make any reportable contributions pursuant to N.J.S.A. 19:44A-1 et seq. that, pursuant to P.L. 2004, c. 19 would bar the award of this contract in the one year period preceding the signed date of the contract to any of the following named candidate committee, joint candidates committee; or political party committee representing the elected officials of the BOROUGH OF SOMERVILLE as defined pursuant to N.J.S.A. 19:44A-3(p), (q) and (r).

Signature and Attestation:

The undersigned is fully aware that if I have misrepresented in whole or part this affirmation and certification, I and/or the business entity, will be liable for any penalty permitted under law.

Name of Business Entity:

Signature of Affiant:

Title:

Printed Name of Affiant:

Date:

Subscribed and sworn before me this day of
, 2.

My Commission expires:

(Witnessed or attested by)

(Seal)