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This form or its permitted facsimile must be submitted to the local unit no later than 10 days prior to the award of the <br />contract. <br /> <br />Part I – Vendor Information <br />Insert vendor name here. <br />Vendor Name: <br />Address:Insert street address here. <br />Insert City Here. <br />City: <br />State:State.Zip:Zip Code <br />The undersigned being authorized to certify, hereby certifies that the submission provided herein represents <br />compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this <br />form. <br />Insert Full Name Insert Title. <br /> <br />Signature of Vendor Printed Name Title <br />Part II – Contribution Disclosure <br />:44A-20.26 this disclosure must include all reportable political <br />Disclosure requirement: Pursuant to N.J.S.A. 19 <br />contributions (more than $300 per election cycle) over the 12 months prior to submission to the committees of the <br />government entities listed on the form provided by the local unit. <br />heck here if disclosure is provided in electronic form. <br />C <br />Contributor Name Recipient Name Date Dollar Amount <br /> $ <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Check here if the information is continued on subsequent page(s) <br />Page | 40 <br /> <br /> <br />