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4. 
6. First Name*
7. Last Name*
9. Email Address*
10. Phone number*
12. Address1*
14. City*
15. State*
16. Zip*
18. Testimony Affirmation
20. I, the undersigned, verify that all statements of fact contained in the attached Statement are true and correct to the best of my knowledge, information, and belief.
    
    I am submitting the attached Statement in lieu of my personal participation in the public hearing, and affirm that I am submitting the Statement because I am unable for good cause to attend the public hearing.
    
    I further understand that I make this Verification subject to the penalties for unsworn falsification provided in Section 4904 of the Pennsylvania Crimes Code, 18 Pa.C.S. section 4904, with respect to all assertions of fact contained in the attached Statement.
22. Type your name here to verify that you read the swearing in statement *
25. Testimony Topic*
27. Attach a file or document here, or type your testimony in the box below.
29. Type Testimony here.
31. When finished, click "Submit" at the bottom of this form.
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