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North Carolina State Firemen's Association 2 <br /> 323 West Jones Street, Suite 401 <br /> Raleigh,NC 27603 <br /> 1-800-253-4733 <br /> 2009 <br /> ANNUAL CERTIFICATION OF FIREMEN <br /> North Carolina General Statute 58-86-25 requires that all certified fire departments submit a complete roster of <br /> its eligible firemen annually. This certified list determines eligibility for the $50,000 line-of-duty death <br /> benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this <br /> information is violation of G.S. 58-86-25 and will automatically result in a loss or reduction of benefits. <br /> REPORT BY FIRE DEPARTMENT CHIEF <br /> As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible <br /> firemen, within the definition contained in North Carolina General Statute 58-86-25. <br /> Name of Fire Department _Ou,f c ScdeTy h1a.✓lw,mef\t <br /> Fire Department Mailing Address 9/0 A e ctdouj iand S U i^V-E- <br /> City 56Z7CC'mk State (�'L- Zip Code <br /> Name of Fire Chief <br /> (Please print or type) <br /> Signature of Fire Chief <br /> Al <br /> Date c. �j "z�O Daytime Telephone_c q ff) 15- 6100 <br /> County O c ay)l N <br /> CERTIFICATION BY GOVERNING BODY <br /> Pursuant to G.S. 58-86-25, the governing body of a fire department operated by (i) a county is the county board <br /> of commissioners, (ii) a city is the city council, (iii) a sanitary district is the sanitary district board, (iv) a <br /> corporation, whether profit or nonprofit, is the corporation's board of directors and (v) any other entity is that <br /> group designated by the board. Therefore, in our capacity as the governing body of the above-named fire <br /> department, we certify and find that the attached roster is a valid and accurate list of all eligible firemen in <br /> accordance with G.S. 58-86-25. <br /> Name of Governing Body <br /> Name of Governing Body Official <br /> (Please print or type) <br /> Authorized Signature Title <br /> Date Daytime Telephone_( <br />