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ADDITIONAL SUBCONTRACTOR NAMES <br />(Legal name of company as registered with the Secretary of State) <br />SUPPLEMENTAL CERTIFICATION <br />Name of city where company home <br />office is located <br />By signing this document I certify that I am an owner or officer of the company, and I swear under oath that: <br />All additional subcontractors listed on Additional Subcontractors List have verified through a signed statement under oath <br />by an owner or officer that they meet the minimum criteria to be a responsible contractor as defined in Minn. Stat. § <br />16C.285. <br />Authorized Signature of Owner or Officer: Printed Name: <br />Title: Date: <br />Company Name: <br />Additional Subcontractors List <br />00 4515-2 <br />