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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 />1, [NAME], [TITLE] for the [AGENCY NAME] declare as follows: <br />I have read the Consent Judgment in People v. Flying Jand, in particular, Paragraph <br />3- Lb. 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. Lb. 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 JInc., Consent Judgment, Exhibit C <br />Page 1 <br />