NYC 9/11 Public Portal Document
?4'97 12:55 CB LtRIA LLP 4 2127321207
NO.564 P003
Dt. Lu•.u1SSI0NER'S UL ILL:111- bby-2fyy4 Uec L4 yf 1u-44 ro.uv r.uz
AVr It1IIIA 11Vn
'file itndcrsigncd Landlord, Lcxsor, Licensor or Optionor affirms and tteclares that said
Landlord, Lessor, Licensor or Optionor is not in arrears to the City of New York upon
debt, contract or taxes and is not a defaulter, as surety or otherwise, upon obligations to
the City of New York, and has not been declared not responsible, or disqualified, by any
agency of the City of Nc+v York, nor is there any proceeding pending relating to the
responsibility or qualification of the propotcr or bidder to receive public contracts
except
Full name of Landlord, Lessor, t c or Qptio
Address ~J a (,
City -~W State Zip Code /l7 l7 S
CHECK ON BOX AND INCLUDE APPROl'RGATE NUMBER
( ] A - Individual or Sole Proprietorship"
SOCIAL SECURITY NUMBER
B - Partnership, Joint Venture or other unincorporated Organization
EMPLOYER IDENTWICA'f(ON N UMBER
P11
( ] C - Corporation
EMPLOYER IDENTIFICATION NUMBER
,G
Signature of an Ofliccr or D Authorized Representative
Ile Date
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 individual's disqualification. Social Security Numbers
will be used to identify Landlords, Lessors, Licensors or Optionurs, to ensure: their
compliance with laws, to assist the City in enforcement of l+aws, as well as to provide
the City a means of identifying buciuccxcc which sock City contracts.
FOR DGS ONLY: T __--
1J 7
Agency Address IPiS Number
NYC-WTC 000169411
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