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Name is/are inoperable. PRINT NAME I certify that all information given on this statement is true and correct. WARNING: SIGNATURE IN INK DATE Misstatement of facts is a misdemeanor of the third degree punishable by fine of up to $2,500.00 and/or imprisonment up to one year (18 Pa. C.S. Section 4904(b)) SEE BACK OF THIS FORM FOR INSTRUCTIONS CUSTOMER INSTRUCTIONS FOR COMPLETING THIS FORM This form is to be comple.

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