et more than S10.000 or by imprisonment of not more than live years or both, and that requesting or obtaining tiny rarord(s) u cr false dierenles is Punishahlo under the provisions / of 5 UU..S.C. SS2a(iX3) by a fine of not more than $5,000. Date /.7/O : • Signature OPTIONAL: A.utStion. to Release