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Exhibit E <br />State Grant Certification - No Overdue Tax Debts' <br />Instructions: Grantee should complete this certification for all state funds received. Entity should enter <br />appropriate data in the yellow highlighted areas. The completed and signed form should be <br />provided to the state agency funding the grant to be attached to the contract for the grant funds. A <br />copy of this form, along with the completed contract, should be kept by the funding agency and <br />available for review by the Office of the State Auditor <br /> <br />To: State Agency Head and Chief Fiscal Officer <br />Certification: <br />We certify that the (irt ~greln~tai~o~'1'8 name) does not have any overdue tax debts, as defined <br />by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person <br />who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense <br />punishable as provided by N.C.G.S. 143-34(b). <br />Sworn Statement: <br />[Nalme ~f 8t>«ard C!'] and [[~~ ~zln~ off] being duly sworn, say that we are <br />the Board Chair and [T~ o~ the $bccrtd ~~$ Oi?l~c~l], respectively, of [~taert nuns of <br />org~ltAticNt] of [City] in the State of [-~tte ~ Stag]; and that the foregoing certification is true, <br />accurate and complete to the best of our knowledge and was made and subscribed by us. We also <br />acknowledge and understand that any misuse of State funds will be reported to the appropriate <br />authorities for further action. <br />Board Chair <br />~a~ saga au~r~~,~o+~aq <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 />If there are any questions, please contact the North Carolina Office of the State Auditor: <br />Leigh Ann Kerr @ (919) 807-7535 or <br />Harriet Abraham @ (919) 807-7673. <br />' G.S. 105-243.1 defines: "Overdue tax debt. -Any part of a tax debt that remains unpaid 90 days or more after <br />the notice of final assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the <br />taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the <br />notice of final assessment was mailed and has not failed to make any payments due under the installment <br />agreement." <br />Page 1 of 1 <br />MS&NCD Form 0008 <br />Eff. July 1, 2005 <br />Revised July 18, 2006, 7/07 <br />