Agenda - 12-10-2013 - 6d - Laserfiche WebLink

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m 2 North Carolina State Firemen's Association 323 West Jones Street,Suite 401 Raleigh,NC 27603 1-800-253-4733 2013; ANNUAL CERTIFICATION OF FIREFIGHTERS *This form MUST 6e filled out and sent in for your Roster Renewal to be complete* s 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 a 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 c( .0 u3 aAl Fire Department Mailing Address �?�1�� t�� c Ci}V- City ) d 4_0 Lkq A _ State d.C Zip Code- _ 9c �V Name of Fire Chief +1&,I�Yiwi (Please print or type) Signature of Fire Chie ,) Date NO`1 Daytime Telephone County �'�.-f 't ,P ff 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 (Please print or type) Authorized Signature Title Date Daytime Telephone_(__