Please certify that the following statements are true. I have disclosed all individuals or entities that hold an ownership interest of greater than 5% or greater than $106,447.20. Yes No I have disclosed all individuals or entities that were entitled to receive distributive income in an amount greater than $106,447.20 or greater than 5% of the total distributive income of the disclosing entity. Yes No OPTION B Disclosure of of Directors (Not-for-Profits) – If you selected Option 5 in Step 1, list members of your of directors. Please include an attachment if necessary. Z – Name Address STEP 3 DISCLOSURE OF LOBBYIST OR (Complete only if bid, offer, or contract has an annual value over $50,000) (Subcontractors with subcontract annual of more than $50,000 must complete) Yes No. Is your company represented by or do you employ a lobbyist required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or other agent who is not identified through Step 2, Option A above and who has communicated, is communicating, or may communicate with any State/Public University officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below. If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information. Name Address Relationship to Disclosing Entity Describe all related to the assistance provided by each representative lobbyist or other agent to obtain this Agency/University contract:
Please certify that the following statements are true. I have disclosed all individuals or entities that hold an ownership interest of greater than 5% or greater than $106,447.20. Yes No I have disclosed all individuals or entities that were entitled to receive distributive income in an amount greater than $106,447.20 or greater than 5% of the total distributive income of the disclosing entity. Yes No OPTION B – Disclosure of of Directors (Not-for-Profits) If you selected Option 5 in Step 1, list members of your of directors. Please include an attachment if necessary. – Z Name Address STEP 3 DISCLOSURE OF LOBBYIST OR (Complete only if bid, offer, or contract has an annual value over $50,000) (Subcontractors with subcontract annual of more than $50,000 must complete) Yes No. Is your company represented by or do you employ a lobbyist required to register under the Lobbyist Registration Act (lobbyist must be registered pursuant to the Act with the Secretary of State) or other agent who is not identified through Step 2, Option A above and who has communicated, is communicating, or may communicate with any State/Public University officer or employee concerning the bid or offer? If yes, please identify each lobbyist and agent, including the name and address below. If you have a lobbyist that does not meet the criteria, then you do not have to disclose the lobbyist’s information. Name Address Relationship to Disclosing Entity Describe all related to the assistance provided by each representative lobbyist or other agent to obtain this Agency/University contract:
Asphalt%20Patching%20Machines%20Statewide%20IFB.docx