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Contract#68-2014 <br /> Senior Care of Orange County,Inc. <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 /> taG...Carc of Dom.-•fie Co,..,,.t,1; s�+c . <br /> Entity's Letterhead r loetnct 6-e-" Soll�s AA - pA,t 1}t�ll{p. ra'�u,.-. <br /> 10 5 la.,A '>r. <br /> [Date of Certification(mmddyyyy)] �ti�tsl oro �•, ^« 2-11-7 � <br /> 0Q 12,5(2013 <br /> To: Orange County Department of Social Services <br /> Certification: <br /> Sev%gpr(yreeFOra.,StCow,j�Tula. <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 ofN.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 /> AUr-y Aan ✓e f-e► -D W 8J w r 1 to rso- <br /> [Name of Board Chair]and[Name of Second Authorizing Official] being duly sworn, say that we <br /> are the Board Chair nd Title�f the Se' on o z n Official],respectively,of[insert name'cr-n-.e�.a„�o�(o.,z <br /> of organization] of�i�y 'iri t`i'e State of °e4do a e ;`ai d 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 /> [Te 7 f eco ,.A�u z,orizi,n�g#-O <br /> fficial]-t np ft.,i <br /> Sworn to and subscribed before me on the daZ,ofltW414tye$f said certification. <br /> �Q-�A __ �My ? <br /> r My Comrji con Expires��I y,&1 <br /> (Notary Signature and Seal) 0 pwp Zr <br /> 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 />