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Authorized Representative Statement: <br /> I certify under penalty of law that this document and all attachments were <br /> prepared under my direction or supervision in accordance with a system designed to assure that <br /> qualified personnel properly gather and evaluate the information submitted . Based on my <br /> inquiry of the person or persons who manage the system , or those persons directly responsible <br /> for gathering the information , the information submitted is , to the best of my knowledge and <br /> belief, true , accurate , and complete. I am aware that there are significant penalties for <br /> submitting false information , including the possibility of fine and imprisonment for knowing <br /> violations . <br /> Name(s) Title <br /> Signature Date Phone <br /> 24 <br />