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HEALTH CARE DIVISION <br />OPERATING ACCEPTANCE STATEMENT <br />Grant # 2008-091 <br />On behalf of the recipient organization, I agree to the terms and conditions set in the attached letter. <br />Furthermore my signature certifies that: <br />1. Income earned on Trust grant funds received by the grantee shall be credited to the available <br />grant funds to be used for the specific purpose described in the grant letter; <br />2. Any funds not used for the purpose granted shall be returned to the Trust; <br />3. Approval must be received from the Trust in writing prior to any modification of the funded <br />program; <br />4. The Trust shall be notified promptly in writing if the organization's tax exemption is <br />revoked or modified in any way; <br />5. The Trust shall be notified in writing of any proposed termination or change in ownership of <br />the organization during the grant period; <br />6. The Trust shall be furnished with annual certified public accounting audits far the duration <br />of the grant period; <br />7. Annual expenditure and program reports shall be furnished to the Trust. (Note: Trust funds <br />shall not be used to pay for sales tax on equipment, construction, and other such items); <br />8. It is understood that, if within one year following the date of the fmal grant distribution, the <br />grantee organization is sold, leased, or otherwise transferred to a party that operates for <br />private gain; or if the grantee organization is sold or otherwise transferred to a successor <br />non-profit entity located outside Forsyth County, the grantee or successor owner must <br />immediately return to the Trust the full amount of the grant. <br />Please checln one: <br />~~We are ready to receive and utilize the funds for the purpose granted. <br />We will request the funds in writing when we are ready to receive and utilize the funds for <br />the purpose granted. <br />~.~~~ <br />Date nn //II - n~--- ~ `~'- ~ ~'' ~~, Board Chair <br />~Y`r~ S~'l KQ ~~"• Orange County Health Department <br />Keep your original letter and a copy of the signed acceptance statement for your files. <br />Return the original signed acceptance statement to the Trust. <br />Revised: 9/17/07 <br />