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-53- <br />STATEMENT BY APPELLANT: <br />I certify that the information presented by me in this application is accurate to the best of my <br />knowledge, information, and b lie . <br />Signature of applicant: <br />Date <br />NOTARY: <br />STATE OF LR14 �9tiIJ . COUNTY OF ( <br />On this day of GPI , 20 i 7-,aa, <br />�A�� IV&nLe4l d- Liwt personally appeared before me and is known <br />to me to be the person who signed the foregoing instrument and he /she acknowledged that <br />he /she signed the same and being duly sworn by me, made oath that the statements in the <br />foregoing instrument are true. <br />Signature of Notary Public <br />My Commission expires: / `�- `--1. `-� — / b <br />MG,CASTRO <br />NOTAAYRWG <br />Sea �MECOUNN <br />WMARMISSIONEXPIAES 12.1416 <br />