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List of Agencies with Elected Officials Required for Political Contribution Disclosure <br />N.J.S.A. 19:44A-20.26 <br />County Name: <br />State: Governor, and Legislative Leadership Committees <br />Legislative District #s: <br />State Senator and two members of the General Assembly per district. <br />County: <br />Freeholders County Clerk Sheriff <br /> {County Executive} Surrogate <br /> <br />Municipalities (Mayor and members of governing body, regardless of title): <br /> <br />USERS SHOULD CREATE THEIR OWN FORM, OR DOWNLOAD FROM WWW.NJ.GOV/DCA/LGS/P2P A COUNTY- <br />BASED, CUSTOMIZABLE FORM. <br />E.Stockholder Disclosure Certification <br />Name of Business: <br /> I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of <br />the issued and outstanding stock of the undersigned. <br /> OR <br /> I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. <br /> <br />Check the box that represents the type of business organization: <br /> Partnership <br /> Corporation <br /> Sole Proprietorship <br /> Limited Partnership <br /> Limited Liability Corporation <br /> Limited Liability Partnership <br /> Subchapter S Corporation <br /> <br />Sign and notarize the form below, and, if necessary, complete the stockholder list below. <br /> <br />Stockholders: <br />Name: Stockholder Name Name: Stockholder Name <br /> <br />Home Address: Home Address: <br />Home Address <br />Home Address <br /> <br />Name: Stockholder Name Name: Stockholder Name <br /> <br />Page | 42 <br /> <br /> <br />