By providing my electronic signature, I hereby affirm that the information on this document and in any attachments is true and correct. I further certify that I am authorized to submit this form on behalf of the applicant.

I also understand that I am under a continuing obligation to notify the Office of the Attorney General of any change in the information provided, and that according to § 13A-9-76(a)(4) of the Code of Alabama, any fraud or misrepresentation when submitting an application is grounds for legal action, which may result in civil penalties along with attorney’s fees and costs.