STATE OF NEBRASKA )
)ss.
COUNTY OF....... )
I,.................. (Purchaser), certify under penalty of perjury that I am not affiliated with any foreign government or nongovernment person determined to be a foreign adversary pursuant to 15 C.F.R. 7.4.
........................... .................................
Signature of Purchaser Date
Neb. Rev. Stat. § 76-NEW