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Administrative Plan 7/1/2025 Page 16-69 <br />This is to certify that the information provided on this form is true and correct to the best of my <br />knowledge, and that the individual named above in Item 1 meets the requirement laid out on this form for <br />an emergency transfer. I acknowledge that submission of false information could jeopardize program <br />eligibility and could be the basis for denial of admission, termination of assistance, or eviction. <br /> <br />Signature __________________________________Signed on (Date) ___________________________ <br />EXHIBIT 1