Disclosure of Political Contributions
Pursuant to Executive Order 134 (“EO 134”) promulgated by the Honorable James E.
McGreevey, Governor of New Jersey, all business entities with which the State intends to
contract are required to disclose all Contributions in excess of $400 (N.J.A.C. 19:25-10(1), et
seq.) from October 15, 2004, through the date of signing of this disclosure, to any entity
designated and organized as a “political organization” under 26 U.S.C.A. 527, that is also defined
as “continuing political committee” under N.J.S.A. 19:44A-3(n) and N.J.A.C. 19:25-1.7.
Indicate “none” if no Contributions are being declared.
Name of 527 Political Organization
Date of
Contribution
Amount of
Contribution
Type of
Contribution
i.e., Cash, Check,
Loan, In Kind
Purpose of 527 Political
Organization
This certification is submitted to the New Jersey Department of Transportation
(“NJDOT”) with knowledge that the NJDOT is relying on the truth of the statements
contained herein.
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.
Name: _______________________
Date: ________________________
Print Name: _____________________