,1O91) , by the undersigned who affirms that the statements made herein are true under- the penal ' of, riesjurg., , --legrt S,...„A MOO a,« • SiVrtelt •Rwl OR Tat 11%I ':202263 931028 000056001539000012 50.00 hart PQ ROAM I 1,40w Ina (Pt * s. EFTA00168506 STATE OF NEW YORK DEPARTMENT OF STAT