ATTACH ADDITIONAL SHEETS IF NECESSARY. INSIDERS -------------------------------------------------------------------------- TYPE OF AMOUNT TOTAL PAID NAME PAYMENT PAID TO DATE -------------------------------------------------------------------------- 1. Xxxx Xxxxxxxxx Xxxxxx $0 $17,200 -------------------------------------------------------------------------- 2. Xxx Xxxxxx Salary $0 $17,200 -------------------------------------------------------------------------- 3. N/A -------------------------------------------------------------------------- 4. N/A -------------------------------------------------------------------------- 5. N/A -------------------------------------------------------------------------- 6. TOTAL PAYMENTS TO INSIDERS $0 $34,400 -------------------------------------------------------------------------- -------------------------------------------------------------------------------------------------------- PROFESSIONALS -------------------------------------------------------------------------------------------------------- DATE OF COURT TOTAL ORDER AUTHORIZING AMOUNT AMOUNT TOTAL PAID INCURRED NAME PAYMENT APPROVED PAID TO DATE & UNPAID* -------------------------------------------------------------------------------------------------------- 1. N/A -------------------------------------------------------------------------------------------------------- 2. N/A -------------------------------------------------------------------------------------------------------- 3. N/A -------------------------------------------------------------------------------------------------------- 4. N/A -------------------------------------------------------------------------------------------------------- 5. N/A -------------------------------------------------------------------------------------------------------- 6. TOTAL PAYMENTS TO PROFESSIONALS $0 $0 $0 $0 -------------------------------------------------------------------------------------------------------- * INCLUDE ALL FEES INCURRED, BOTH APPROVED AND UNAPPROVED ----------------------------------------------------------------- POSTPETITION STATUS OF SECURED NOTES, LEASES PAYABLE AND ADEQUATE PROTECTION PAYMENTS ----------------------------------------------------------------- ------------------------------------------------------------------------------------------- SCHEDULED AMOUNTS MONTHLY PAID TOTAL PAYMENTS DURING UNPAID NAME OF CREDITOR DUE MONTH POSTPETITION -----------------------------------------------------------------------------------...
ATTACH ADDITIONAL SHEETS IF NECESSARY. In the alternative, to comply with the ownership disclosure requirement, a Vendor {Bidder} with any direct or indirect parent entity which is publicly traded may submit the name and address of each publicly traded entity and the name and address of each person that holds a 10 percent or greater beneficial interest in the publicly traded entity as of the last annual filing with the federal Securities and Exchange Commission or the foreign equivalent, and, if there is any person that holds a 10 percent or greater beneficial interest, also shall submit links to the websites containing the last annual filings with the federal Securities and Exchange Commission or the foreign equivalent and the relevant page numbers of the filings that contain the information on each person that holds a 10 percent or greater beneficial interest. N.J.S.A. 52:25-24.2. Signature (Do not enter vendor ID as a signature) Date Print Name and Title FEIN/SSN CERTIFICATION I, the undersigned, certify that I am authorized to execute this certification on behalf of the Vendor {Bidder}, that the foregoing information and any attachments hereto, to the best of my knowledge are true and complete. I acknowledge that the State of New Jersey is relying on the information contained herein, and that the Vendor {Bidder} is under a continuing obligation from the date of this certification through the completion of any contract(s) with the State to notify the State in writing of any changes to the information contained herein; that I am aware that it is a criminal offense to make a false statement or misrepresentation in this certification. If I do so, I will be subject to criminal prosecution under the law, and it will constitute a material breach of my agreement(s) with the State, permitting the State to declare any contract(s) resulting from this certification void and unenforceable. STATE OF NEW JERSEY DEPARTMENT OF THE TREASURY DIVISION OF PURCHASE AND PROPERTY 00 XXXX XXXXX XXXXXX, X.X. XXX 000 XXXXXXX, XXX XXXXXX 00000-0000 DISCLOSURE OF INVESTIGATIONS AND OTHER ACTIONS INVOLVING THE VENDOR {BIDDER} FORM PART 1 PLEASE LIST ALL OFFICERS/DIRECTORS OF THE VENDOR {BIDDER} BELOW. IN PART 2 OF THIS FORM, YOU WILL BE REQUIRED TO ANSWER QUESTIONS REGARDING THESE INDIVIDUALS. BID SOLICITATION #: VENDOR {BIDDER}: OFFICERS/DIRECTORS NAME XXXXX XXXXXXX 0 XXXXXXX 0 XXXX XXXXX ZIP NAME TITLE ADDRESS 1 ADDRESS 2 CITY STATE ZIP NAME TITLE ADDRESS 1 ADDRESS 2 CITY STATE ZIP Attach Additional Sheets If Necessar...
ATTACH ADDITIONAL SHEETS IF NECESSARY. Describe your Research Project. Itemize your working timetable for completing the research described above. Include the number of projected meetings with the supervising faculty member, use of USC research facilities, and work to be done off-campus. Please indicate how your research will be presented: Substantive paper, formal publication, demonstration/performance, film or digital production – explain) I agree to complete the course of study outlined above. SIGNED DATE
