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s <br /> i <br /> If Sub-contractor is a sole proprietorship, list: <br /> Sub-contractor Name <br /> Phone <br /> Mailing Address <br /> City State Zip <br /> SSN EIN <br /> 6, VERIFICATION <br /> i <br /> I certify under penalty of the Act (Public Law 95-87) thatlI <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 <br /> of tho <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 submit n false information, <br /> including the possibility of fine and im isonment (U Co <br /> Title 18, Sec. 1001) . <br /> Signature of Responsible Office <br /> Title °C i�orrt Date <br /> Subscribed and sworn to before me by <br /> 2 ^-> 1997. <br /> This 3 day of <br /> Notary Public <br /> My Commission expires: i <br /> i <br /> i <br /> I <br /> i <br /> I <br /> i <br /> I� <br />