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O BEFORE ME: MONTH DAY YEAR SIGNATURE OF PERSON ADMINISTERING OATH S T A M P I/We state that I/we have read and signed this form after its completion, and I/we swear or affirm that the statements made herein are true and correct, and that any statement made on or pursuant to this form is subject to the penalties of 18 PA C.S. Section 4903(a)(2)(relating to false swearing), which shall include punishment of a fine not exceeding $5,000, or to a term or imprisonment of not more than two years.

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