BID FORM 5

DISCLOSURE STATEMENT

N.J.S.A. 40A:9-22.1 et seq.

(Must be completed for Response to be accepted.)

The attention of Bidders is drawn to the provisions of the Local Government Ethics Law (N.J.S.A. 40A:9-22-1, et seq.) which prohibits a Borough Officer or employee or member of his/her immediate family from having an interest in a business organization or engaging in any business, transaction, or professional activity, which is in substantial conflict with the proper discharge of his duties in the public interest.

In furtherance thereof, every Bidder must disclose below, being a Borough Officer or employee or whether an immediate family member is a Borough Officer or employee. If the Bidder is a business organization, then disclosure shall be made with respect to anyone having an interest in the business and their immediate family members.

Please answer the following:

Is the Bidder or a member of the Bidder’s immediate family, or anyone having an interest in the Bidder’s business organization including their immediate family members, an officer or employee of the Borough?

NO X
YES  

If yes, provide the name of the individual and identify the position held, below, and notify, in writing, to the Borough Administrator, 25 West End Ave, Somerville, NJ 08876 (Attach copy of correspondence to this form.)

NOTE: All terms used herein are to be construed in accordance with their meaning under the Local Government Ethics Law, cited above.

Name of Bidder:
NEW JERSEY-AMERICAN WATER COMPANY, INC.
Authorized Signature:
Authorized Signature of Vice President, Operations
Title:
VICE PRESIDENT, OPERATIONS
Date:
6/17/2022
#3176895
C-9