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19 <br />contract #68-Zoos <br />Arcadia Health Services, Inc. <br />ATTACIiMENT E <br />OVERDUE TAXES <br />Orange County Department of Social Services <br />Instructions: Grantee should complete this certification for all fluids 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 orgaizization's name) does not have any overdue tax debts, as <br />defined by N.C.G.S. lOS-243.1, at the federal, State, or local level. We fiu-ther 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 />(Notary Signature and Seal) <br />My Commission Expires: <br />Overdue Taxes - (07/08) Page 1 of 1 <br />