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I swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen and/or I am lawfully present in the United States pursuant to Federal law. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. By signing this form, I certify that I purchased the fixtures or appliances as stated above and plan to install it (them) at the address indicated above within the Town of Erie service area.
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