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I NAVE.P ERSONALLY EXAMINED J. uL +~ ~, ' .:~ ' <br />r ~ "' ~ <br />~ TElEPf10NE <br />`- , O AT E ~ <br />~ ~ <br /> AND A M FAMILIAR WTM 3HEINFORMATION.SUBMITT EO HEREIN; A NO BASED • <br />rLV . <br />~_ . <br />" <br />T1' _ r. :;; ~.{~ C ~ <br />~~ -: ~' -' ~ ~'rt; 3 7v'~•'.D <br />' ` '' <br />~ ON MY INQUIRY OF AIOSE INDIVIDUALS IMMEDIATELY RESPONSIBLE~FOR <br />OBTAINING •THE INFORMATION. 1=8EOEVE TRE'SUBMITTED INFORMATON~ _ <br />p~ ~ D ~ <br />I,,.- <br />a~ <br />~ <br />~ 1 T. .~ •- - p •~- <br />~+'Q ^O~ O ~u <br />~ u <br />I <br />~ ~ <br />'~ K -_~' ~ <br />~ <br />~ ~ TRUE. ACOUMTE'AND•CAMPLETEI AM AWARETNAT THERE ARE SIG.. , <br />=' <br />_ , <br />,y ~ <br />' ~. m ~ E <br />u <br />-" <br />I u Y .4 <br />' <br />1''l <br />' <br />_ <br />NLAl~'AA P~~;de T. K <br />~ ~'~~ t' - ^~' ~ n ' ~~ ' ~ :NIFICANT PENALTEyy~~FOR SUBMITRNG~FALSE,INFORMATION_ INCLUDING <br />THE POSSIBIITTY OFtINE AND IIiPA150NMEN 'SES 18 US.C_{ glXlt'ANO <br />S <br />~J9 U <br />C <br />P 1319 <br />n <br />: <br />kb UA <br />a <br />r <br />l <br />d <br />-i <br />J7 <br />~ <br />M'A <br />A <br />d %f " <br />_ <br />y ~ 'a ~ <br />SIGNATUREOF PRINCIPAL E7~ECUTIVE <br />' ~ O ~ <br />•. <br />-,G ID <br />~~• ~~/7.~ u <br />~ ate' <br />~ ~1=• <br />~i ~I <br />15 <br />-_ '_~":,tTYP.ED ORPRINTED ~ - rt'T!'I' . <br />. <br />. <br />. / <br />e <br />v <br />r <br />v <br />erm <br />me <br />o <br />0.aD <br />n <br />r <br />,I~ <br />P ; <br />.AIWOrI,r®TYU1 in,Pd+aelrlem 0/brwa,Qnranrbmd Jews/ - ~ - ,~ <br />r OFFCER OR AUTHORIZED <br />AGENT +- REK :.J';MUYBEA `E <br />- - ]~'EI[A YO I DAY <br />_ <br />+__ _ -- - _ _ _ - •.w :;.,,::.: .. r,r- <br />NATION OF ANY VIOFJ.T10NSyRe/sm,adf afinehmrnv hoe/-:- <br />A <br />-- <br />_:::;:•I <br />COMMEN <br />LfND EXPL <br />t - ~ r:.; <c.,r - <br />~ <br />T <br />, <br />_ <br />~ <br />, <br />lTO.lYTT~~ ~l9_P.RTAS F.--SPR".3f il?]T!J (1T£ C~/_ ~DA~F• 7 AF-R4~. 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