Agenda - 01-20-2011 - 4h - Laserfiche WebLink

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2 North Carolina State Firemen's Association 323 West Jones Street, Suite 401 Raleigh, NC 27b03 1-800-253-4733 North Carolina General Statute 58-86-25 requires that all certified fire departments submit a complete roster of its eligible firemen annually. This certified list determines eligibility for the $50,000 line-of--duty death benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this information is violation of G.S. 58-86-25 and will automatically result in a loss or reduction of benefits. REPORT BY FIRE DEPARTMENT CLEF As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible firemen, within the definition contained in North Carolina General Statute S8-8b-2S. Name of Fire Department (~k'/3i/GL-f ~ cI~JTy' G/(~f S/~-!'G' i }' d1'i!~ ~~6Grl~Gl~ Fire Department Mailing Address S'~/O /~j Gj/It~~t,,/ G/-~~/!~S pI'~/ yG1 City ~/L~SljynauGl~ State N ~ Zip Code ~ ~~ ~ Name of Fire Chief 1~A y ~D .~'Y,~S~ (Please print or type) Signature of Fire Chief ~~~ ~~~- Date `y ~ ZZ r Zd j~ Daytime Telephone _( / ~1) ~ ~ ~ ~/y ~ County f~~H~JC~Is CERTIFICATION BY GOVERNING BODY Pursuant to G.S. S8-8b-25, the governing body of a fire department operated by (i} a county is the county board of commissioners, {ii) a city is the city council, (iii) a sanitary district is the sanitary district board, (iv) a corporation, whether profit or nonprofit, is the corporation's board of directors and {v) any other entity is that group designated by the board. Therefore, in our capacity as the governing body of the above-named fire department, we certify and find that the attached roster is a valid and accurate list of all eligible firemen in accordance with G.S. S8-8b-25. Name of Governing Body Name of Governing Body Official Authorized Signature 2010 ANNUAL CERTIFICATION OF FIREMEN (Please print or type} Title Date Daytime Telephone.