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<br /> <br /> <br />PART VI - CERTIFICATION <br /> <br />I hereby certify that the information provided in this disclosure is true and correct and I am aware that <br />any false information or lack of information knowingly made or omitted may subject me to civil or <br />criminal penalties under Section 1001 of Title 18 of the United States Code. In addition, I am aware <br />that if I knowingly and materially violate any required disclosure of information, including intentional <br />nondisclosure, I am subject to a civil money penalty not to exceed $10,000 for each violation. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> (Chief Elected Official) <br /> <br /> <br /> <br /> <br /> <br /> <br /> (Date) <br />