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Contract #68-2013 ~ ~ <br />Dr. Betty Rintoul <br />ATTACHMENT E <br />OVERDUE TAXES <br />Orange County Department of Social Services <br />Instructions: Grantee should complete this certification for all funds received. Entity <br />should enter appropriate data in the yellow highlighted areas. The completed and signed <br />form must be provided to the County Department of Social Services. <br />Entity's Letterhead <br />jDate of Certification (mmddyyyy)] <br />To: Orange County Department of Social Services <br />Certification: <br />We certify that the [insert organization's name] does not have any overdue tax debts, <br />as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. We further <br />understand that any person who makes a false statement in violation of N.C.G.S. 143- <br />6.2(b2) is guilty of a criminal offense punishable as provided by N.C.G.S. 143-34(b). <br />Sworn Statement: <br />[Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, <br />say that we are the Board Chair and [Title of the Second Authorizing Offcial], <br />respectively, of jinsert name of organization] of [City] in the State of [Name of State]; <br />and that the foregoing certification is true, accurate and complete to the best of our <br />knowledge and was made and subscribed by us. We also acknowledge and understand <br />that any misuse of State funds will be reported to the appropriate authorities for further <br />action. <br />Board Chair <br />[Title of Second Authorizing Official] <br />Sworn to and subscribed before me on the day of the date of said certification. <br />(Notary Signature and Seal) <br />My Commission Expires: <br />Overdue Taxes - (06/04) Page 1 of 1 <br />