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I certify that the facts set forth in this statement are true and correct to the best of my knowledge, information or belief. This verification is made subject to the penalties set forth in the Pennsylvania Crimes Code, Section 4904 (18 PA., C.S. 4904) relating to Unsworn Falsification to Authorities.

Note: By clicking the “submit” button, you acknowledge that you are aware of the seriousness of these allegations and making false statements may result in you being charged under Section 4904, as listed above.