Instructions on filling out Public Disclosure Form
A business which enter into contracts, leases or other agreements with the State, or its units, in which the business receives a total of $100,000 or more, is required to file with the Secretary of State a form containing the name and address of any resident agent of the business, each officer of the business and, if known, each person who has a beneficial ownership of the business. Statutory Authority: State Finance & Procurement Article, §13-221 of the Annotated Code of Maryland. 1. You may either print the blank form out and complete and mail back to this office. 2. Place mouse cursor on the line in the first box. 3. To see a highlighted view of where the fields are, in the upper right hand corner of Adobe Reader, there is "Highlight Fields" button click this button. 4. Formats have been provided in the date and number boxes. 5. Hit the tab or enter button to move from box to box. Not all text boxes are visible but are provided. 6. Where necessary, you have the option of hitting return for multiple lines. (i.e. addresses) 7. Once you have completed the form, print and mail to: Office of the Secretary of State, State House, Annapolis, MD 21401 When form is completed, click the "Print Form" button next to the "Highlight Fields" button or use the Print button from your menu bar.
Public Disclosure of Persons Whose Business with the State Exceeds $100,000
This form is to be filed within 30 days of the date when the total value of business with the State of Maryland reaches $100,000 in any calendar year. Please type or print clearly. This filing is for Calendar Year __________ (yyyy) Print this form, complete it and mail to: Financial Disclosures, Office of the Secretary of State, State House, Annapolis, Maryland 21401 For assistance, call: (410) 974-5521 ext. 3859 or 888-874-0013 ext. 3859 (toll free in Maryland) or e-mail your question to us
Name of person, corporation or business entity making disclosure:
Date of disclosure:
Nature of Business:
Address of discloser:
Name & address of resident agent of corporation (if applicable):
Name & address of each officer of the corporation or (in the case of nonprofit organizations), the board of directors. Use additional sheet, if necessary.
Name & address, if known, of each person who has beneficial ownership of the business as defined in §13-221 (use an additional sheet, if necessary)
Name of person responsible for filling out this form (please print clearly) _________________________________________________________________________ Title: __________________________ Telephone no.: _____________________ Email address: __________________________
I do solemnly affirm under the penalties of perjury that the contents of this document are true to the best of my knowledge, information, or belief.
Date _________________________________ Name of Individual or Chief Executive Officer of Organization (Type or Print) _________________________________________ Signature of Individual or Chief Executive Officer of Organization
Note: This statement will be retained by the Office of the Secretary of State as a public record for at least two years from the date of receipt. The statement will be available for examination and copying by the public during business hours, subject to such reasonable fees and administrative procedures as the Secretary may establish. This form may be printed directly from the Internet, or the information may be sent on company letterhead.