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If Sub-contractor is a sole proprietorship, list: <br />Sub-contractor <br />Mailing Address <br />City <br />SSN <br />Name <br />Phone <br />State Zip <br />6. VERIFICATION <br />EIN <br />i certify under penalty of the Act (Public Law 95-87) that I <br />am a responsible official (as identified in item 3 or 7) for <br />this proposed operation, that I have personally examined and <br />am familiar with the information submitted in this disclosure <br />and all attachments, and that, based on my inquiry of those <br />persons immediately responsible for obtaining the information <br />contained in this disclosure, i believe that the information <br />is true, accurate, and complete. I am aware there are <br />significant penalties for submitting fakse information, <br />including the possibility of fine and imprisonment (IIS Code <br />Title 18, Sec. 1001). % <br />Signature of Responsible Office ~ <br />TitlePresident <br />Date 07/01/96 <br />Subscribed aad sworn to before me by p /A,l <br />_~ <br />This <br />Notary Public <br />1st day of July , <br />My Commission expires <br /> <br />~~ <br />