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. t . <br /> STATEMENT , <br /> O// /ziI / c igg7 c <br /> 1/ Vs--- / 71/1 i. 7 Ito' laer,4410 1/4/ i-t_e b 1. 4O1 'xi' <br /> z.0 R4u)irkeeid__ --ii 60Afp 1/11-Igh-e7 5 ,, <br /> -(0/d1�1 G 7 (v 1 c1 fiZe-e4/ kj _fv1-1._ / /(4,1,--)e . <br /> Alla4,,,A.,-,,,,06 . • ,, 0 I C!_-_ _______ ______ <br /> C.—SI-41Y LLA-UVZ-- o ' ° 31-filtAr -2 <br /> I -- - u---C-P S i.' 4 / G'_P'a-`" zyr/J-- <br /> &A,ne „-- .I 7,,k-fp k - s off.. <br /> CD/ te 5 i fvvi /3J/ , / . . I _s-;,4,10.) <br /> A1-)-( e)1&_ I+ 1( ,-S raiKa --Hi•-k I (/ -1 --/- /s--i-lt) -KL?.L.L_ <br /> bo 4,, Q (2 t° ° , f PLO <br /> I have read the foregoing statement and it is true and made by my own free will . <br /> 6` <br /> � J��/ SIGNED: _ <br /> PARENT'S SIGNATURE //te/MIVA-Q___' ! <br /> 9 ,,y ;la !o <br /> Witr.ess: <br /> V—R1X2 Time : . 5O PM <br /> Witness : ��jCc.,� ( • -)-'‘ ,_ :._--,1 Date <br /> . C ,7 ( / / --':7 <br /> 1 <br />