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Contract#68-2004 <br /> Personalized Patient Home Assistance,Inc. <br /> ATTACHMENT E <br /> OVERDUE TAXES <br /> Orange County Department of Social Services and Orange County Department on Aging <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 De artment of Social Se is Q �✓� h C•Q <br /> 1) c P, <br /> EEntity's er ead <br /> n <br /> 01, ;? Of <br /> [Date of Certification(mmddyyyy)] <br /> To: Orange County Department of Social Services <br /> Certification: PP*�t,r W <br /> We certify that the [insert org nation'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 /> awn r- <br /> [Name ofesrd- ir] 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 actin .��"OSRYAG� <br /> �. �......•,,•rye,,, <br /> /VQT•'• 'Z <br /> e h = ' C-$ <br /> Title of Second Authorizing Official? �< C `�co <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> My Commission Expires: 7',.,!`! 7 <br /> (Notary S y ature and Seal) <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 />