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Page 20 of 54 <br />DisclosureActof1995engagedbythereporting entityidentifiedinitem4toinfluencethecovered <br />Federalaction. <br />(b) Enter the full names of the individual(s) performing services, and include full address if different from <br />10 (a). Enter Last Name, First Name, and Middle Initial (MI). <br />11. The certifying official must sign and date the form, print his/her name, title, and telephone number. <br /> <br /> <br />According to the Paperwork Reduction Act, as amended, no persons are required to respond to a collection of information unless it displays a valid OMB Control Number. The <br />valid OMB control number for this information collection is OMB No. 0348-0046. Public reporting burden for this collection of information is estimated to average 10 <br />minutes per response, including time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing <br />the collection of information. Send comments regarding the burden estimate or any other aspect of this collection of information, including suggestions for reducing this <br />burden, to the Office of Management and Budget, Paperwork Reduction Project (0348-0046), Washington, DC 20503.