"I certify under the penalty of perjury that to the best of my knowledge and belief the statements made and information given herein are true. I further certify that this submission is in compliance with M.G.L. c. 21J and 503 CMR 2.00. I hereby consent to all audits of payment and necessary inspections made to verify the accuracy of any submission to the Board or DOR and made pursuant to law and incidental to the issuance of licenses, registrations, permits, certificates and the operation of an UST System. I am aware that there are significant penalties for submitting false information, including possible fines, civil penalties and imprisonment. I further certify that I am authorized to execute this form. I agree to return any erroneous payment to the Fund within ten days of either the receipt of the erroneous payment or the receipt of a written notice from the Board or DOR that an erroneous payment was made."
A Board member who complies with the provisions of M.G.L. c. 268A pertaining to conduct of public officials and employees shall be deemed to be in compliance with the provisions of the UST statute at M.G.L. c. 21J, § 8 related to qualifications and limitations by Board Members in their participation on Board matters.
All forms may be reproduced or computer-generated provided that copies are reproduced identically or as close to identical as feasible. In no case shall language substitutions be acceptable.
503 CMR, § 2.03