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Exhibit C <br /> People v. Flying J <br /> Initial Penalty Payment to Certified Unified Program Agencies("CUPAs") <br /> CUPA Declaration <br /> Paragraph 3.Lb. <br /> The declaration referred to in Paragraph 3.Lb. shall take the following form: <br /> I, [NAME], [TITLE] for the[AGENCY NAME] declare as follows: <br /> I have read the Consent Judgment in People v. Flying J and,in particular,Paragraph <br /> 3.1.b.and Exhibit B to the Consent Judgment. Under the Consent Judgment,[AGENCY <br /> NAME] is to receive$[AMOUNT]under Paragraph 3.Lb. <br /> I understand and will ensure that the payment received pursuant to Paragraph 3.l.b.will <br /> be placed into a special account, to be expended only to fund the activities of[AGENCY <br /> NAME] in enforcing Chapter 6.7,Division 20,Health and Safety Code within the agency's <br /> jurisdiction pursuant to Chapter 6.11,Division 20,Health and Safety Code. This special account <br /> has been established and is ready to received the payment specified in Paragraph 3.Lb. <br /> I declare under penalty of perjury that the foregoing is true and correct. <br /> [DATE AND PLACE] <br /> [SIGNATURE] <br /> People v.Flying J Inc.,Consent Judgment,Exhibit C <br /> Page i <br />