Vendor Certification And Disclosure Of Political Contributions Form Page 2
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1
2Public Law 2005, Chapter 51
Vendor Certification and Disclosure
of Political Contributions (2 Years)
(formerly Executive Order 134)
Vendor:
EIN:
(9 digits)
Type of
Name and Address of
Date of
Amount of
Contribution, i.e.,
Donor
Committee
Contribution
Contribution
Currency, Check,
Loan, In Kind
Indicate “none” if no contributions were made. Attach additional pages if necessary.
1
Certification on behalf of a COMPANY or organization:
I certify as an officer or authorized representative of the Company or Organization identified below that, to the best of my
knowledge and belief, the foregoing statements by me are true. I am aware that if any of the statements are willfully false,
I am subject to punishment.
I certify that the firm has not made a contribution that would bar the award of a contract pursuant to Public Law 2005,
Chapter 51 [N.J.S.A. 19:44A-20.13-20.25, superseding Executive Order 134 (2004)].
NOTE: This certification will be in effect for two (2) years provided the ownership status does not change or additional
contributions are not made.
If there are any changes in the ownership of the entity affecting persons or organizations
owning more than 10%, or additional contributions are made, a new full set of documents are required to be completed
and submitted. By submitting this Certification and Disclosure, the person or entity named herein acknowledges this
reporting responsibility and certifies that it will adhere to it.
Name of Company or Organization: _______________________________________________________
2
Signed: ___________________________________
Title: ____________________________________
Print Name: _______________________________
Date: ____________________________________
(check one) (A)
The Company or Organization is the vendor, or (B)
the Company or Organization is a
Principal (more than 10% ownership or control) of the vendor, a Subsidiary controlled by the vendor, or a
Political Organization (e.g., PAC) controlled by the vendor.
Certification by an individual – for use by the individual vendor, or as a Principal (more than 10% ownership
or control) of the vendor, or as the spouse or child of the vendor:
I certify that, to the best of my knowledge and belief, the foregoing statements by me are true. I am aware that if any of
the statements are willfully false, I am subject to punishment.
NOTE: This certification will be in effect for two (2) years provided the ownership status does not change or additional
contributions are not made.
If there are any changes in the ownership of the entity affecting persons or organizations
owning more than 10%, or additional contributions are made, a new full set of documents are required to be completed
and submitted. By submitting this Certification and Disclosure, the person or entity named herein acknowledges this
reporting responsibility and certifies that it will adhere to it.
Signed: ___________________________________
3
Print Name: _______________________________
Date: ____________________________________
A person may certify BOTH as an officer or authorized representative of the vendor, AND in his or her individual
capacity, as a Principal of the vendor.
DPP c51 - C&D, Rev. 10-23-2008
Page 2 of 2
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