C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM

Required Pursuant To N.J.S.A. 19:44A-20.26

This 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 Information

Vendor Name:	NEW JERSEY-AMERICAN WATER COMPANY, INC.
Address:	1 WATER STREET
City:	CAMDEN	State:	NJ	Zip:	08102

The undersigned being authorized to certify, hereby certifies that the submission provided herein represents compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this form.

Signature

Thomas Shroba

Printed Name

Vice President, Operations

Title

Part II – Contribution Disclosure

Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable political contributions (more than $300 per election cycle) over the 12 months prior to submission to the committees of the government entities listed on the form provided by the local unit.

Check here if disclosure is provided in electronic form.

Contributor Name	Recipient Name	Date	Dollar Amount $
N/A - Given that this RFB is being conducted via a competitive process and the instructions for this 271 Disclosure Form make it clear that this disclosure is required only when a contract is not being awarded pursuant to a fair-and-open process, it is our understanding that this disclosure is not required in connection with this proposal.

Check here if the information is continued on subsequent page(s)