Application Form For Parties Wishing To Offer, Render, Furnish, Or Supply Electricity Or Electric Generation Services To The Public In The Commonwealth Of Pennsylvania Page 18

Appendix A

APPLICATION AFFIDAVIT

[Commonwealth/State] of _____________________________ :

ss.

County of _________________________

________________________, Affiant, being duly [sworn/affirmed] according to law, deposes and says that:

[He/she is the _____________________ (Office of Affiant) of ___________________ (Name of Applicant);]

[That he/she is authorized to and does make this affidavit for said Applicant;]

That the Applicant herein __________________ has the burden of producing information and supporting documentation

demonstrating its technical and financial fitness to be licensed as an electric generation supplier pursuant to 66 Pa. C.S. §

2809 (B).

That the Applicant herein ___________________ has answered the questions on the application correctly, truthfully, and

completely and provided supporting documentation as required.

That the Applicant herein __________________ acknowledges that it is under a duty to update information provided in

answer to questions on this application and contained in supporting documents.

That the Applicant herein __________________ acknowledges that it is under a duty to supplement information provided

in answer to questions on this application and contained in supporting documents as requested by the Commission.

That the facts above set forth are true and correct to the best of his/her knowledge, information, and belief, and that he/she

expects said Applicant to be able to prove the same at hearing.

_______________________________________

Signature of Affiant

Sworn and subscribed before me this ________ day of ________________, 20____.

_______________________________________

Signature of official administering oath

My commission expires ____________________________.

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