HomeMy WebLinkAboutVendor Bidder Disclosure1 V• T Al VA it ea T
Vendor/Bidder Disclosure
I, , being first duly sworn state that:
The full legal name and business address of the person(s) or entity contracting with the
Town of Davie ("Town") are as follows (Post Office addresses are not acceptable):
Name of Individual, Firm, or Organization:
Address:
FEIN
State and date of incorporation
OWNERSHIP DISCLOSURE AFFIDAVIT
1. If the contract or business transaction is with a corporation, the full legal name and
business address shall be provided for each officer and director and each stockholder
who directly or indirectly holds five percent (5%) or more of the corporation's stock. If
the contract or business transaction is with a trust, the full name and address shall be
provided for each trustee and each beneficiary. All such names and address are as
follows (Post Office addresses are not acceptable):
Full Legal Name
Address Ownership
2. The full legal names and business addresses of any other individual (other than
subcontractors, materialmen, suppliers, laborers, and lenders) who have, or will have,
any legal, equitable, or beneficial interest in the contract or business transaction with the
Town are as follows (Post Office addresses are not acceptable):
Full Legal Name Address
By: Date:
Signature of Affiant
Print Name
SUBSCRIBED AND SWORN TO or affirmed before me this day of
200 , by , he/she is
personally known to me or has presented as
identification.
Notary Public, State of Florida at Large
Print or Stamp of Notary
Serial Number
My Commission Expires