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accordance with a system designed to assure that qualified <br />personnel properly gather and evaluate the information submitted. <br />Based on my inquiry of the person or person's directly responsible <br />for gathering the information, the information submitted is, tot he <br />best of my knowledge and belief, true, accurate and complete. I am <br />aware that there are significant penalties for submitting false <br />information, including the possibility of fine and imprisonment for <br />knowing violations. <br />