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36 <br />Contract Number 00027858 / Page 33 of 33 <br />(c) He or- she understands that any person who knowingly submits a false certification shall be guilty <br />of a Class i felony„ <br />©zange County, NC <br />Contractor's Name <br />w- <br />Signature of Contract s Authorized Agent Date , <br />Printed Name ofjContractor's Authorized`Agent _• Tide ; <br />Signature of Witness Title <br />Name of Witness <br />Date <br />The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document <br />immediately thereafter <br />Page 2 of 2 <br />