Form 22 - Suffolk County Contractor'S/vendor'S Public Disclosure Statement 2013 Page 2
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2Form 22 – Contractor/Vendor’s Public Disclosure Statement continued….
shall be entitled, upon a determination that a breach has occurred, to damages equal to fifteen percent (15%) of
the amount of the Contract.
12.
Verification. This section must be signed by an officer or principal of the Contractor/vendor authorized to sign
for the company for the purpose of executing Contracts. The undersigned being sworn, affirms under the
penalties of perjury, that he/she has read and understood the foregoing statements and that they are, to his/her
own knowledge, true.
Dated: ______________ Signed: __________________________________________________________
Printed Name of Signer:
__________________________________________________________
Title of Signer:
__________________________________________________________
Name of Contractor/Vendor:
__________________________________________________________
UNIFORM CERTIFICATE OF ACKNOWLEDGMENT
(Within New York State)
STATE OF NEW YORK)
COUNTY OF
) ss.:
On the ____ day of ______________ in the year _____ before me, the undersigned, personally appeared
____________________ personally known to me or proved to me on the basis of satisfactory evidence to be the
individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that he/she/they
executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.
_______________________________________________
(Signature and office of individual taking acknowledgement)
(Notary Public)
UNIFORM CERTIFICATE OF ACKNOWLEDGEMENT
(Without New York State)
STATE OF
)
)ss.:
COUNTY OF
)
On the________day of___________________ in the year ______before me, the undersigned, personally
appeared_________________________ personally known to me or proved to me on the basis of satisfactory evidence
to be the individual(s) whose name(s) is (are) subscribed to the within instrument and acknowledged to me that
he/she/they executed the same in his/her/their capacity(ies) and that by his/her/their signature(s) on the instrument, the
individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument, and that such
individual(s) made such appearance before the undersigned in
___________________________________________________________________________________________
(Insert the city or other political subdivision and the state or country or other place the acknowledgement was taken)
_________________________________________________
(Signature and office of individual taking acknowledgement)
(Notary Public)
Page 2 of 2
Rev. 5/2013
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