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AFFIDAVIT OF VERIFICATION

In RE:____________________:

AFFIDAVIT STATEMENT

I,________________________, hereby depose and say that I am personally familiar with the Applicant, ____________________, and that the facts set forth herein in this Affidavit Exhibit A and the attached statement from Applicant stating the reason for their request to receive financial assistance are true and correct to the best of my knowledge, and belief and that I take this Affidavit pursuant to the penalties of 18 PA C. S. S 4904 relating to unsworn falsification to authorities:

1. My name, address, phone number, and e-mail address are as follows:

(All information must be supplied)

__________________________
__________________________
__________________________

__________________________

2. I am personally familiar with Applicant, ________________________, having known the Applicant for at least ______ years & _____ months.

3.I have read the request for financial Assistance made by the applicant and I believe that the statements made therein are true and correct.

4. I find the Applicant, ______________________, to be honest, of good character and competence.

5. __ I am related by __ blood or __ marriage to the Applicant, (check & state how) _____________________________________________________________________.

6. __I am not related by blood or marriage to the Applicant.

SWORN TO AND SUBSCRIBED

BEFORE ME THIS_______DAY OF

________________, 200_

Respectfully submitted,

_______________________
(Print Name)

_______________________
(Signature)

NOTARY PUBLIC

Exhibit A