Agenda - 01-22-2009 - 4p - Laserfiche WebLink

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Exhibit E State Grant Certification No Overdue Tax Debts Instructions: Grantee should complete this certification for all state funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form should be provided to the state agency funding the grant to be attached to the contract for the grant funds. A copy of this form, along with the completed contract, should be kept by the funding agency and available for review by the Office of the State Auditor Entity's ilrrlltd Wets of COriffklatkon(n )] To: State Agency Head and Chief Fiscal Officer Certification: We certify that the [heart tation's name) does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143-34(b). Sworn Statement: [Name of Board Chi] and [Nizator0 Second,Aathogzing official] being duly sworn, say that we are the Board Chair and [Title of the Second Auth obi], respectively, of[knot name of organization] of[City] in the State of[Wine of Mato]; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Board Chair [Mid Se o AuthoitintiOnidan Sworn to and subscribed before me on the day of the date of said certification. My Commission Expires: (Notary Signature and Seal) If there are any questions,please contact the North Carolina Office of the State Auditor: Leigh Ann Kerr @(919)807-7535 or Harriet Abraham @(919)807-7673. 1 G.S. 105-243.1 defines: "Overdue tax debt.—Any part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer.The term does not include a tax debt, however, if the taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement." Page 1 of 1 MS&NCD Form 0008 Eff.July 1,2005 Revised July 18,2006,7/07