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Contract '~l~ L86076- t 08 <br />Noiih Carolina I3aPtist I lospital <br />ATTACHMENT E -OVERDUE TAXES <br />Instructions: Grantee should complete this certification for all funds received. Entity should enter appropriate <br />data in the yellow highlighted areas. The completed and signed form must be provided to the County <br />Department of Social Services. <br />Entity's Letterhead <br />[Date of Certification (mmddyyyy)] <br />i`c>: ()ranl;e ('t~ctnt~' C)cp~'t°tn~c°nt ts9°~;~~ci:ai'ticrtiaces <br />Certification: /, <br />/Vo/~lr Le~~-Lin. ~itr~jr3-~ f~f~~st l <br />We certif that the - ~~ -'' "" '." "" ..r~~cres not have any overdue tax debts, as defined by <br />Y ~:. <br />N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a <br />false statement in violation of N.C.G.S. 143C-6-23is guilty of a criminal offense punishable as provided by <br />N.C.G.S.143C-10-1). <br />Sworn Statement: <br />[ being duly sworn, say that we are the Board <br />Chair and [Title of the Second Authorizing Official], respectively, of [insert name of organization] of [City] in <br />the State of [Name of State]; and that the foregoing certification is true, accurate and complete to the best of our <br />knowledge and was ade and subscribed by us. We also acknowledge and understand that any misuse of State <br />funds will be report to the appropriate authorities for further action. <br />7s-sa,~r !~..~G~iY.~s <br /> <br />Sworn to and subscribed before me on the day of the date of said certification. <br />My Commission Expires:ll ~ -l '~" <br />(Notary Si~ature <br />ETTYE J. SMITI <br />Nara~r Pueuc <br />Fonaytl~ County, Nor, <br />MV Canmission Exoires <br />Contract-General (06/04) Page 15 of 19 <br />