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Contract 468 -2001 <br />Holcomb and Cabe, L.L.P. <br />ATTACHMENT E <br />OVERDUE TAXES <br />Orange County Department of Social Services <br />Instructions: Grantee /Provider should complete this certification for all funds received. Entity <br />should enter appropriate data in the yellow highlighted areas. The completed and signed form <br />must be provided to the County Department of Social Services. <br />Entity's Letterhead <br />[Date of Certification (mmddyyyy)] <br />To: Orange County Department of Social Services <br />Certification: <br />We certify that the [insert organization's name] 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. We 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(b). <br />Sworn Statement: <br />[Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we <br />are the Board Chair and [Title of the Second Authorizing Official], respectively, of [insert name <br />of organization] of [City] in the State of [Name of State]; and that the foregoing certification is <br />true, accurate and complete to the best of our knowledge and was made and subscribed by us. <br />We also acknowledge and understand that any misuse of State funds will be reported to the <br />appropriate authorities for further action. <br />Board Chair <br />[Title of Second Authorizing Official] <br />Sworn to and subscribed before me on the day of the date of said certification. <br />My Commission Expires: <br />(Notary Signature and Seal) <br />1 G.S. 105 -243.1 defines: Overdue tax debt. — Any part of a tax debt that remains unpaid 90 days or more after the <br />notice of final assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the taxpayer <br />entered into an installment agreement for the tax debt under G.S. 105 -237 within 90 days after the notice of final <br />assessment was mailed and has not failed to make any payments due under the installment agreement." <br />Overdue Taxes — (07/08) Page 1 of 1 <br />