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federal or State Convict]ons, Judements, Settlements <br /> E olanat on <br /> (use continuation sheet, if necessary) <br /> CERTIFICATION <br /> under..penalty of Perjury that i have Personally examined and am familiar with the information submittec �r+ <br /> this disclosure statement, and believe that the submitted information is true, accurate and complete. I am aware <br /> that there are significant penalties for providing false information, including the possibility of fine and/or <br /> imprisonment. I also certify that I am authorized to sign this disclosure statement on behalf of the applicant Of <br /> applicant and signer are different). <br /> Executed this�day ofb t <br /> ItT1�j , �O /- � <br /> City state <br /> Signa ure 0 <br /> Typed Name1 �Title <br /> Address <br /> Phone Number <br /> Page 7 <br />