Section E: Certification
IMPORTANT: Making a false statement in this certification may subject you to criminal prosecution for a misdemeanor or felony under the New York State Penal Law.
The person signing below, declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:
1. he/she is the certifying official/provider whose name and contact information appears above;
2. the certifying official/provider has undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and has sufficient knowledge to complete this form; and
3. the certifying official/provider acknowledges that this certification is being made in order to comply with the requirements outlined in the questions answered above.