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Contract #68-2006 <br />Triangle Home Health Care, Inc. <br />II. The site(s) for the performance of work done in connection with the specific agreement are <br />.listed below: <br />1. J r <br />(Street address) <br />(City, county, state, zip code) <br />2. <br />(Street address) <br />(City, county, state, zip code) <br />Contractor will inform the County of any additional sites for performance of work under this <br />agreement. <br />False certification or violation of the certification shall be grounds for suspension of payment, <br />suspension or termination of grants, or government-wide Federal suspension or debarment <br />(Section 4 CFR Part 85, Section 85.615 and 86.620). <br />• <br />• <br />Signature Title ' <br />~~~ ~ 1~~~ <br />Agenc rganization ~~n..c_ <br />Date <br />(Certification signature should be same as Contract signature.) <br />Federal Certification -Drug-Free Workplace (06/04) <br />Page 2 of 2 <br />