NYC 9/11 Public Portal Document
?y37 12:55 CARB LURIA LLP -> 2127321207 NO. 564 P003
Obo Lu.h-iSSIONEK 'S UH ILL • 212-bby-byy2 uec yr 10 = 44 NO.uud r . uz
Ai'r_mwiA 1 ion
The iindcrsiBncd Landlord, Lessor, T/iccnsor or Optionor affirms and declares that said
Landlord, Lessor, Licensor or Optionor is not in arrears to the City of New York upon
debt, contract or (axes and is not a deraulter, as surety or olher^vite, upon obligations to
(he City of New York, and has not been declared not responsible, or disqualified, by any
agency of the City of Nnv York, nor is there any proceeding pending relating to the
responsibility or qualification of the proposer or bidder to receive public contracts
except
Full name of Landl^.^Lwop^Ucowyi^^^^gtio^^^^^^^^
Address.
Cily. er\£. Zip Code //? S
CHECK ON BOX AND INCLUDE ArPROritGUE NUMBER
[1 A - Individual or Sole Proprietorship*
SOCIAL SECURITY NUMBER
WB- Partnership, Joint Venture or other unincorporated Organization
EMPLOYER IDENTIFICATION N UMBER
.......... PH..........
(] C - Corporation
EMPLOYER IDENTIFICATION NUMBER
Signature of an Officer or DI|^ Authorized Representative
TWe Dale
If a corporation place seal here:
* Under the Federal Privacy Act the furnishing of Social Security Numbers by
Individuals on City City contracts is voluntary. Failure to provide a Social Security
Number will not result in an individuaPs disqualification. Social Security Numbers
will be used to identify Landlords, Lessors, Licensors or Optiouurs, to ensure their
compliance with laws, to assist the City in enforcement ofbiws, as well as to provide
the City a means of identifying businesses which .seek City contracts.
FOR DCS ONLY;
Agency Address 11’IS Number
I'
NYC-WTC_000169411
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