Orange County NC Website
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(b) He or she is authorized to make, and does hereby make, theQb@bV ►i�o*mffXM?6MZjiFh*jAW 19 <br /> the Contractor; and <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 /> Orange County Department on Aging <br /> Contractor's Name <br /> Si a e of Contractor's Aighorized Agent Date <br /> Printed Name of Contr or's Authorized Agent Title <br /> 1161 , <br /> Signature of Witne s Title <br /> Printed Name 6f Witness 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 />