By signing this document, I certify that I have read this document, fully understand it and that I am not relying on any statement or representations of any of the Released Parties. This document shall be binding upon my heirs, executors, administrators, assigns and me.

I Swear or affirm that the above information is true to the best of my knowledge at the time of my signature. I understand that falsifying this information may lead to denial of assistance, and/or The Sunflower Foundation collecting any funds I may receive with false information by any means necessary. The Sunflower Foundation is a 501(c)(3) non-profit organization focused on Suicide Awareness and Intervention within the local community