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STATEMENT OF <br />ELECTED/APPOINTED OFFICER <br />do solemnly swear (or affirm), <br />that I have not directly or indirectly paid, offered, promised to pay, contributed, or <br />promised to contribute any money or thing of value, or promised any public office or <br />employment for the giving or withholding of a vote at the election at which I was <br />elected or as a reward to secure my appointment or confirmation, whichever the case <br />may be, so help me, God. <br />UNDER PENALTIES OF PERJURY, I DECLARE THAT I HAVE READ THE FOREGOING <br />STATEMENT AND THAT THE FACTS STATED THEREINARE TRUE. <br />-L 6 - -2 <br />Date <br />to Which <br />Form No. 2201 <br />S gnature of officer <br />