Agenda - 01-24-2013 - 5k - Laserfiche WebLink

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North Carolina State Firemen's Association 323 West Jones Street, Suite 401 Raleigh, NC 27603 1- 800 - 253 -4733 2012 ANNUAL CERTIFICATION OF FIREFIGHTERS *This form MUST be filled out and sent in for your Roster Renewal to be complete* North Carolina General Statute 58 -86 -25 requires that all certified fire departments submit a complete roster_ of its eligible firemen annually. This certified list determines eligibility for the $50,000 line-of-duty death benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this information is violation of G.S. 58 -86 -25 and will automatically result in a loss or reduction of benefits. REPORT BY FIRE DEPARTMENT CHIEF As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible firemen, within the definition contained in North Carolina General Statute 58- 86 -25. Name of Fire Department Fire Department Mailing Address .51e) ��a e� bnt , city 88i t S LG —o C (4A State AJ Zip Code Name of Fire Chief l (Please print or type) Signature of Fire Chief Date Daytime Telephone _7r ) _aq-5 6 /epo CERTIFICATION BY GOVERNING BODY Pursuant to G.S. 58- 86 -25, the governing body of a fire department operated by (i) a county is the county board of commissioners, (ii) a city is the city council, (iii) a sanitary district is the sanitary district board, (iv) a corporation, whether profit or nonprofit, is the corporation's board of directors and (v) any other entity is that group designated by the board. Therefore, in our capacity as the governing body of the above -named fire department, we certify and find that the attached roster is a valid and accurate list of all eligible firemen in accordance with G.S. 58- 86 -25. Name of Governing Body Name of Governing Body Official Authorized Signature Date Daytime Telephone_ (Please print or type) Title