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19 <br /> Contract#68-2005 <br /> Arcadia Health Services,Inc. <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 should <br /> enter appropriate data in the yellow highlighted areas. The completed and signed form must be <br /> provided to the County Department of Social Services. <br /> Entity's Letterhead <br /> [Date 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,as <br /> defined by N.C.G.S. 105-243.1,at the federal,State,or local level. We further understand that <br /> any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c)is guilty of a <br /> criminal offense punishable as provided byN.C.G.S. 143C-10-1. <br /> Sworn Statement: <br /> [Name of Board Chair]and[Name of Second Authorizing Official]being duly sworn,say that we <br /> are the Board Chair and[Title of the Second Authorizing Official],respectively, of[insert name <br /> of organization] of[City]in the State of[Name of State];and that the foregoing certification is <br /> true,accurate and complete to the best of our knowledge and was made and subscribed by us. <br /> We also acknowledge and understand that any misuse of State funds will be reported to the <br /> appropriate authorities for further 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 /> My Commission Expires: <br /> (Notary Signature and Seal) <br /> Overdue Taxes—(07/08) Page 1 of 1 <br />