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Disclosure Statement of Criminal Conviction Pursuant to P. L. 2004 chapter 26 the following statement must be completed and filed with the Nomination Petition Please Check Applicable Box I the undersigned hereby certify that in accordance with N.J.S.A. 19 23-15 I have not been convicted of any offense graded by Title 2C of the New Jersey Statutes as a crime of the first second third or fourth degree or an offense in any jurisdiction which if comm.

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