Orange County NC Website
Browse       Search
Q <br />North Carolina State Firemen's Association <br />323 West Jones Street, Suite 401 <br />Raleigh, NC 27603 <br />1-800-253-4733 <br />2007 <br />ANNUAL CERTIFICATION OF FIREMEN <br />North Carolina General Statute 58-86-25 requires that all certified fire departments submit a complete roster of* <br />its eligible firemen annually.. This certified list determines eligibility for the $50,000 line-of-duty death <br />benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this <br />information is violation of G.S. 58-86-25 and will automatically result in a loss or reduction of benefits. <br />REPORT BY FIRE DEPARTMENT CHIEF <br />As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible <br />firemen, within the definition contained in North Carolina General Statute 58-86-25.. <br />Name of Fire Department QjA/46,F a UN Ty /l12? M4R S A'It S D 4r-yfCe- <br />Fite Department Mailing Address PC). -Rtix 9 19 r <br />City (ct-sao je ou i* State Zip Code ?a <br />Name of Fire Chief' -7Y l / Ke <br />(Please print or type) <br />Signature of Fire Chief' 0 ?LG 16wln? <br />Date C9/4/0 O Daytime T elephone <br />County 00W GA5- ' <br />CERTIFICATION BY GOVERNING BODY <br />Pursuant to G.S.. 58-86-25, the governing body of•a fire department operated by (i) a county is the county board <br />of commissioners, (ii) a city is the city council, (iii) a sanitary district is the sanitary, district board, (iv) a <br />corporation, whether profit or nonprofit, is the corporation's board of'directors and (v) any other entity is that <br />group designated by the board.. Therefore, in our capacity as the governing body of the above-named fire <br />department, we certify and find that the attached roster is a valid and accurate list of all eligible firemen in <br />accordance with G.S.. 58-86-25. <br />Name of Governing Body 04Ai., C- Car??V ?"? ?j?/-?12? D? U?yat'T ?o rn /n l S-s l?? EQS <br />Name of Governing Body Official ,G R-V J AQ /-& 5 <br />(Please print or type) <br />Authorized Signature <br />ritle L'GIAazz.,, <br />Date . Daytime Telephone( q[ o'?11-5' - 02f ' 0