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<br />ADDRESS [• U d G e. II C A }i Y U }I '+ I X
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<br />NAME/t'TTLE PRINCIPAL EXECUTIVE OFFICER I CERTIFr UNDER PENILLTY OF L
<br />AM FAMILIAR WITH THE INFOR AW THAT I HAVE PERSO
<br />MATION SUBMITTED H NALLY EXAMINED AN
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<br />MID BASFD
<br />'~ TELEPHONE DATE
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<br />MY INOV1Rr OF THO4E INDIVIDUAL4 IMMEDIATELr RESPOM4IBLE F ~
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<br />JOHN M WALTERS OBTAINING THE INFORMATON, 1 BELIEVE THE 4UBMITTED INFORMATION 1
<br />TRUE. ACCURATE AND COMPLETE. I AM AWARE THAT iNERE ARE
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<br />MANAGER OF MINE SERVICES SIGNIFICANT PENALTIES FOR SUBMITTING FALSE INFORMATION, INCLWINO
<br />THE P059BILITY OF RNE AND IMPRISONMENT. SEE iB U.S.C. E 1001 MID ]]
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<br />DAY
<br />COMMENTS AND EXPLANATION OF ANY VIOLATIONS /Rs/erence ell ettechments here)
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