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<br />If Sub-contractor is a sole proprietorship, list: <br />Sub-contractor Name <br />Mailing Address <br />City <br />SSN <br />State Z <br />6. VERIFICATION <br />EIN <br />Phone <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 false information, <br />including the possibility of fine and imprisonment (QS Code <br />Title 18, Sec. 1001). <br />Signature of Responsible Officer <br />Title <br />Date <br />Subscribed and sworn to before me by <br />This <br />day of 19, <br />Notary Public <br />My Commission expires: <br />