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Contract#68-2014 <br /> Senior Care of Orange County, 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 orrunial on s nwxnre 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 by N.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 /> � �(4 <br /> Board Chair <br /> M 4.u, i7 <br /> [Title of Second Authorizing Official] <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> ` • ; ' O My Commission Expires: `10-aoi7 <br /> ( ►tA :`gnature <br /> er <br /> ao <br /> eft otary to <br /> al <br /> AID <br /> iltibll0 Z <br /> Overd f l Page I of I <br />