the Items of Informedon entered on thls form an hue and correct Ito the Oat of my knowledge and IseiSf) and intends's] that the meting of any withal Vitas statement of manta: fact herein will subject me to the prods Iona of Medal& Lew reistve to the making and Mat of tals. Inatnonenta. BUYER_ I !all:

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