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APPENDIX E <br />o AFFIDAVIT <br />4 I, 'l �V4,4,c., swear or affirm under penalty of perjury under the laws of the State of <br />Colorado that (check one): <br />if I am a United States citizen, or <br />I am a Permanent Resident of the United States, or <br />I am lawfully present in the United States pursuant to Federal law. <br />I understand that this sworn statement is required by law because I have applied for a public <br />benefit. I understand that state law requires me to provide proof that I am lawfully present in the <br />United States prior to receipt of this public benefit. I further acknowledge that making a false, <br />fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the <br />criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8- <br />503nd it shall constitute a separate criminal offense each time a public benefit is fraudulently <br />received. <br />Signature <br />1/;4f1k <br />Date <br />20 <br />L \FRIEDLANVNy Documents L\CDBG\2016 CDBG-DR IGA Lowsville_FINAL docx 3/15/2016 <br />