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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. SENIOR CARE OF ORANGE COUNTY <br /> DBA SOLTYS ADULT DAY HEALTH <br /> Entity's Letterhead P O BOX 8181 <br /> 105 MEADOWLAND DR <br /> [Date of Certification(mmddyyyy)] HILLSBOROUGH,NC 27278 <br /> 7lzlIIy <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. 105-243.11, 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 /> 5al�r ,,,,..•a DOW'.) wi I Xevor, <br /> [N �f RQard( hair] and Official] being duly sworn,say that we a( F <br /> are the Board Chairl��} ecrnz 1g Official],respectively,of[i ;t ate " �r�-� Cp-.43, <br /> afsrga Nation] of m t` ie State of 7;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 /> appropri aut ritie or further action. <br /> j <br /> ar ha' <br /> l° ruthuilzi ig C3ft cial]' <br /> I YGaS�+�✓ <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> My Commission Expires: c/— 2019 <br /> (Notary Signature and Seal) DANA S HALL <br /> Notary Public <br /> Orange Co.,North Carolina <br /> My Commission E*r68 Mar.9,2019 <br /> G.S. 105-243.1 defines:Overdue tax debt.—Any PM L 01 it LUX CUM 61M IvinaftfrMw id 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) Pagel of 1 <br />