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North Carolina State Firemen's Association <br />323 West Jones Street, Suite 401 <br />Raleigh, NC 27603 <br />1-800-253-4733 <br />2011 <br />ANNUAL CERTIFICATION OF FIREFIGHTERS <br />North Carolina General Statute 58-$6-25 requires that all certified fire departments subrriit 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 defmition pcontained in North Carolina General Statute 5 8-86-25. <br />Name of Fire Department - ®/~ ~~~ ~ ~O Lt1 SIT `~ ~..~-~~ ~~ /~~ ~i{~ ~~~ <br />Fire Department Mailing Address ~,/b /l~ f~.flC~alL~Nl~s ~} ~~ (~~ <br />City ~~-L~ ~~ (ZD ~/~ State /(J [~ Zip Code ~. ~ a <br />Name of Fire Chief ~ F} VZ I~ S ~/~ = ,Cj <br />(Please print or type) <br />Signature of Fire Chief ~~, <br />Date ~ - ~ ~ ° ~O /a, Daytime Telephone _( ~ q) ~ ~° (U ~ QO <br />County d ~~ /if <br />2 <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 />