FAILURE OF THE BIDDER/RESPONDENT TO SUBMIT THE REQUIRED INFORMATION IS CAUSE FOR AUTOMATIC REJECTION CHECK ONE: I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. Legal Name of Business_______________________________________________________ Respondent’s Check which business entity applies: Partnership Corporation Sole Proprietorship Limited Partnership Limited Liability Partnership Limited Liability Corporation Subchapter S Corporation Other __ Complete if the bidder/respondent is one of the 3 types of Corporations: Date Incorporated: Where Incorporated: __ Business Address: Street Address City State Zip Telephone # Fax # Email Listed below are the names and addresses of all stockholders, partners or individuals who own 10% or more of its stock of any classes, or who own 10% or greater interest therein. Name Home Address Name Home Address Continue on Additional Sheets if Necessary: Yes No Signature: Date: Printed Name and Title: SOMERSET COUNTY LIBRARY SYSTEM NON-COLLUSION AFFIDAVIT State of _____________ County of _____________ ss:
FAILURE OF THE BIDDER/RESPONDENT TO SUBMIT THE REQUIRED INFORMATION IS CAUSE FOR AUTOMATIC REJECTION CHECK ONE: I certify that the list below contains the names and home addresses of all stockholders holding 10% or more of the issued and outstanding stock of the undersigned. I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the undersigned. Legal Name of Respondent’s Business_______________________________________________________ Check which business entity applies: Partnership Corporation Sole Proprietorship Limited Partnership Limited Liability Partnership Limited Liability Corporation Subchapter S Corporation Other __ Complete if the bidder/respondent is one of the 3 types of Corporations: Date Incorporated: Where Incorporated: __ Business Address: Street Address City State Zip Telephone # Fax # Email Listed below are the names and addresses of all stockholders, partners or individuals who own 10% or more of its stock of any classes, or who own 10% or greater interest therein. Name Home Address Name Home Address Continue on Additional Sheets if Necessary: Yes No Signature: Date: Printed Name and Title: SOMERSET COUNTY LIBRARY SYSTEM NON-COLLUSION AFFIDAVIT State of _____________ County of _____________ ss:
HealthInsuranceConsultantRFP-October2016.docx