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PERSONALIZED PATIENT HOME ASSISTANCE <br /> 109 Concord Drive <br /> Chapel Hill,North Carolina 275116 <br /> June .2.t ,2012 <br /> To: Orange County Department of Social Services <br /> CERTIFICATION: <br /> I certify that Personalized Patient Home Assistance 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. I 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 /> Dorothea Farrington,being duly sworn, say that I am the owner of Personalized Patient Home <br /> Assistance of Chapel Hill in the State of North Carolina; and that the foregoing certification is <br /> true, accurate and complete to the best of my knowledge and was made and subscribed by me. I <br /> also acknowledge and understand that any misuse of State funds will be reported to the <br /> appropriate authorities for further action. <br /> `�.•`000111RY199,si <br /> VZ <br /> G +z: -41 o_ <br /> G * <br /> 0. '� .e <br /> OWNER 04".•..,.,... •,.� <br /> itosionsoo- <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> i. 0 My Commission Expires:ti" <br /> Notary 'ignature and Seal <br />