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Contract#68-2013 <br /> Dr. Betty Rintoul <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 /> Betty Rintoul,Ph.D. <br /> 7/01/2012 <br /> To: Orange County Department of Social Services <br /> Certification: <br /> I certify that 1 do not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the <br /> federal, State,or local level. I further understand that any person who makes a false statement in <br /> violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by <br /> N.C.G.S. 143C-10-1. <br /> Sworn Statement: <br /> Betty Rintoul, being duly sworn, say that I am the solo proprietor of Betty Rintoul, Ph.D., a <br /> consulting psychology practice of Carrboro in the State of North Carolina; and that the foregoing <br /> certification is true, accurate and complete to the best of my knowledge and was made and <br /> subscribed by me. I also acknowledge and understand that any misuse of State funds will be <br /> reported to the appropriate authorities for further action. <br /> ( <br /> Betty Rintoul, h.D. <br /> SINorn to and subscribed before me on the day the date of said certification. <br /> 1111kMy Commission Expires: <br /> (Notary Signature and Seal) <br /> Page 1 of <br /> Overdue Taxes- (07/08) <br />