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Political Contribution Disclosure Form

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Executive Summary

This document provides instructions and forms related to Political Contribution Disclosure requirements for contractors in New Jersey. Contractors receiving contracts exceeding $17,500 that are not awarded through a "fair and open" process must disclose political contributions made to various political committees. The disclosure must be submitted at least 10 days before the contract award and include contributions exceeding $300 per election cycle made within the 12 months prior to the contract award. Contractors must also complete a Stockholder Disclosure Certification.

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--- Document: Political Contribution Disclosure Form Document ---
C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM 
 
Public Agency Instructions 
 
This page provides guidance to public agencies entering into contracts with business entities that are 
required to file Political Contribution Disclosure forms with the agency.  It is not intended to be 
provided to contractors. What follows are instructions on the use of form local units can provide to 
contractors that are required to disclose political contributions pursuant to N.J.S.A. 19:44A-20.26 (P.L. 
2005, c. 271, s.2).  Additional information on the process is available in Local Finance Notice 2006-1 
(http://www.nj.gov/dca/divisions/dlgs/resources/lfns_2006.html). Please refer back to these instructions 
for the appropriate links, as the Local Finance Notices include links that are no longer operational. 
 
1. The disclosure is required for all contracts in excess of $17,500 that are not awarded pursuant to 
a “fair and open” process (N.J.S.A. 19:44A-20.7). 
2. Due to the potential length of some contractor submissions, the public agency should consider 
allowing data to be submitted in electronic form (i.e., spreadsheet, pdf file, etc.).  Submissions 
must be kept with the contract documents or in an appropriate computer file and be available for 
public access.  The form is worded to accept this alternate submission.  The text should be 
amended if electronic submission will not be allowed. 
3. The submission must be received from the contractor and on file at least 10 days prior to award 
of the contract.  Resolutions of award should reflect that the disclosure has been received and is 
on file. 
4. The contractor must disclose contributions made to candidate and party committees covering a 
wide range of public agencies, including all public agencies that have elected officials in the 
county of the public agency, state legislative positions, and various state entities.  The Division of 
Local Government Services recommends that contractors be provided a list of the affected 
agencies.  This will assist contractors in determining the campaign and political committees of the 
officials and candidates affected by the disclosure. 
a. The Division has prepared model disclosure forms for each county.  They can be 
downloaded from the “County PCD Forms” link on the Pay-to-Play web site at 
http://www.nj.gov/dca/divisions/dlgs/programs/lpcl.html#12. They will be updated from 
time-to-time as necessary. 
b. A public agency using these forms should edit them to properly reflect the correct 
legislative district(s).  As the forms are county-based, they list all legislative districts in 
each county.  Districts that do not represent the public agency should be removed 
from the lists. 
c. Some contractors may find it easier to provide a single list that covers all contributions, 
regardless of the county.  These submissions are appropriate and should be accepted. 
d. The form may be used “as-is”, subject to edits as described herein. 
e. The “Contractor Instructions” sheet is intended to be provided with the form.  It is 
recommended that the Instructions and the form be printed on the same piece of paper.  
The form notes that the Instructions are printed on the back of the form; where that is not 
the case, the text should be edited accordingly. 
f. The form is a Word document and can be edited to meet local needs, and posted for 
download on web sites, used as an e-mail attachment, or provided as a printed document. 
5. It is recommended that the contractor also complete a “Stockholder Disclosure Certification.”  
This will assist the local unit in its obligation to ensure that contractor did not make any 
prohibited contributions to the committees listed on the Business Entity Disclosure Certification 
in the 12 months prior to the contract.  (See Local Finance Notice 2006-7 for additional 
information on this obligation at http://www.nj.gov/dca/divisions/dlgs/resources/lfns_2006.html)  
A sample Certification form is part of this package and the instruction to complete it is included 
in the Contractor Instructions.  NOTE:  This section is not applicable to Boards of Education. 


C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM 
Contractor Instructions 
 
Business entities (contractors) receiving contracts from a public agency that are NOT awarded pursuant to 
a “fair and open” process (defined at N.J.S.A. 19:44A-20.7) are subject to the provisions of P.L. 2005, c. 
271, s.2 (N.J.S.A. 19:44A-20.26).  This law provides that 10 days prior to the award of such a contract, the 
contractor shall disclose contributions to:  
• 
any State, county, or municipal committee of a political party 
• 
any legislative leadership committee* 
• 
any continuing political committee (a.k.a., political action committee) 
• 
any candidate committee of a candidate for, or holder of, an elective office: 
o of the public entity awarding the contract 
o of that county in which that public entity is located 
o of another public entity within that county 
o or of a legislative district in which that public entity is located or, when the 
public entity is a county, of any legislative district which includes all or part of 
the county 
The disclosure must list reportable contributions to any of the committees that exceed $300 per election 
cycle that were made during the 12 months prior to award of the contract.  See N.J.S.A. 19:44A-8 and 
19:44A-16 for more details on reportable contributions. 
 
N.J.S.A. 19:44A-20.26 itemizes the parties from whom contributions must be disclosed when a business 
entity is not a natural person.  This includes the following: 
• 
individuals with an “interest” ownership or control of more than 10% of the profits or assets 
of a business entity or 10% of the stock in the case of a business entity that is a corporation 
for profit 
• 
all principals, partners, officers, or directors of the business entity or their spouses 
• 
any subsidiaries directly or indirectly controlled by the business entity 
• 
IRS Code Section 527 New Jersey based organizations, directly or indirectly controlled by 
the business entity and filing as continuing political committees, (PACs). 
When the business entity is a natural person, “a contribution by that person’s spouse or child, residing 
therewith, shall be deemed to be a contribution by the business entity.” [N.J.S.A. 19:44A-20.26(b)]  The 
contributor must be listed on the disclosure. 
Any business entity that fails to comply with the disclosure provisions shall be subject to a fine imposed 
by ELEC in an amount to be determined by the Commission which may be based upon the amount that 
the business entity failed to report. 
The enclosed list of agencies is provided to assist the contractor in identifying those public agencies whose 
elected official and/or candidate campaign committees are affected by the disclosure requirement.  It is the 
contractor’s responsibility to identify the specific committees to which contributions may have been made 
and need to be disclosed.  The disclosed information may exceed the minimum requirement. 
The enclosed form, a content-consistent facsimile, or an electronic data file containing the required details 
(along with a signed cover sheet) may be used as the contractor’s submission and is disclosable to the 
public under the Open Public Records Act. 
The contractor must also complete the attached Stockholder Disclosure Certification.  This will assist the 
agency in meeting its obligations under the law. NOTE:  This section does not apply to Board of 
Education contracts. 
* N.J.S.A. 19:44A-3(s):  “The term "legislative leadership committee" means a committee established, authorized to 
be established, or designated by the President of the Senate, the Minority Leader of the Senate, the Speaker of the 
General Assembly or the Minority Leader of the General Assembly pursuant to section 16 of P.L.1993, c.65 
(C.19:44A-10.1) for the purpose of receiving contributions and making expenditures.” 


 C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM 
Required Pursuant To N.J.S.A. 19:44A-20.26 
 
This form or its permitted facsimile must be submitted to the local unit  
no later than 10 days prior to the award of the contract. 
 
Part I – Vendor Information 
Vendor Name: 
 
Address: 
 
City:  
State: 
Zip: 
 
The undersigned being authorized to certify, hereby certifies that the submission provided herein represents 
compliance with the provisions of N.J.S.A. 19:44A-20.26 and as represented by the Instructions accompanying this 
form. 
 
 
_________________________      
____________________________ 
_________________________ 
Signature 
 
 
 
Printed Name  
 
 
Title 
Part II – Contribution Disclosure 
 
Disclosure requirement: Pursuant to N.J.S.A. 19:44A-20.26 this disclosure must include all reportable 
political contributions (more than $300 per election cycle) over the 12 months prior to submission to the 
committees of the government entities listed on the form provided by the local unit. 
 
 Check here if disclosure is provided in electronic form. 
 
Contributor Name 
Recipient Name 
Date 
Dollar Amount 
 
 
 
$ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Check here if the information is continued on subsequent page(s) 


Continuation Page 
C. 271 POLITICAL CONTRIBUTION DISCLOSURE FORM 
Required Pursuant To N.J.S.A. 19:44A-20.26 
 
Page ___ of ______ 
 
Vendor Name:  
 
Contributor Name 
Recipient Name 
Date 
Dollar Amount 
 
 
 
$ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Check here if the information is continued on subsequent page(s) 


List of Agencies with Elected Officials Required for Political Contribution Disclosure 
N.J.S.A. 19:44A-20.26 
County Name:   
State: Governor, and Legislative Leadership Committees 
Legislative District #s:  
State Senator and two members of the General Assembly per district. 
 
County:  
 
Freeholders 
 
 
County Clerk  
Sheriff 
 
{County Executive}  
Surrogate 
 
 
 
Municipalities (Mayor and members of governing body, regardless of title): 
 
 
 
 
 
USERS SHOULD CREATE THEIR OWN FORM, OR DOWNLOAD 
FROM the Pay to Play section OF THE DLGS WEBSITE A 
COUNTY-BASED, CUSTOMIZABLE FORM. 
 


STOCKHOLDER DISCLOSURE CERTIFICATION  
 
 
Name of Business:   
 
 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. 
 
 
 
 
 
OR 
 I certify that no one stockholder owns 10% or more of the issued and outstanding stock of the 
undersigned. 
 
Check the box that represents the type of business organization: 
 
Partnership 
 
Corporation 
 
 
Sole Proprietorship 
Limited Partnership 
Limited Liability Corporation 
Limited Liability Partnership 
Subchapter S Corporation 
 
Sign and notarize the form below, and, if necessary, complete the stockholder list below.  
 
Stockholders: 
 
Name:  
Name:  
 
Home Address:  
 
 
Home Address:  
 
Name:  
Name: 
 
Home Address:  
 
 
Home Address:  
Name:  
 
Name:  
 
Home Address:  
 
Home Address:  
 
 
Subscribed and sworn before me this ___ day of ___________, 2 
__. 
 
(Notary Public) 
 
My Commission expires: 
 
 
_________________________________ 
(Affiant) 
 
________________________________ 
(Print name & title of affiant) 
 
(Corporate Seal)