2015-152 Aging - NC Division of Aging and Adult Services - Amendment to Contract dated 3-22-2013

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State CfabtHkAt`>lomber 00028582,Amendment Number 2/Page 12 of 12 Contractor Certifications Required by North Carolina Law Instructions The person who signs this document should read the text of the statutes listed below and consult with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes can be found online at: • Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLezislatio.n/Statutes/PDF/By.Aiticle/Chapter 64/Article 2.udf • G.S. 105-164.8(b): http://www ncga state nc us/EnactedLegislation/Statutes/PDF/BySection/Chgpter 105/GS 105-164.8.pdf • G.S. 143-48.5: http•//www ncga state nc us/EnactedLepislation/Statutes/HTML/BySection/Chapter 143/GS 143-48.5.1itml • G.S. 143-59.1: http•//www ncga state nc us/EnactedLegislation/Statutes/PDFBySection/ChVter 143/GS 143-59.1.pdf • G.S. 143-59.2: http•//www ncga state nc us/EnactedLegislation/Statutes/PDF/BySection/ChUter 143/GS 143-59.2.pdf • G.S. 147-33.95(g): http://www ncga state nc us/EnactedLegislation/Statutes/Hnfi,BySection/Chapter 147/GS 147-33.95.html Certifications (1) Pursuant to G.S. 143-48.5 and G.S. 147-33.95(8), the undersigned hereby certifies that the Contractor named below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E-Verify system." E-Verify System Link: www.uscis.gov (2) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor"as set forth in G.S. 143-59.1(a)because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105-164.8(b);and (b) [check one of the following boxes] ® Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven country"as set forth in G.S. 143-59.1(c)(2)after December 31,2001;or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country" as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. (4) The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor;and (c) He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59.land-59.2 shall be guilty of a Class I felony. Orange County Department on Aging Contractor's Name Q�� . /, �;4� Si toe of Contractor's Auth6fized Agent Date LIZ I.Tyler Director Printed Name of Contractor's Authorized Agent Title Z85—e�Signature of ness Da e Mary E.Fraser Administrator Printed Name of Witness Title The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter. Contractor Certifications Required by North Carolina Law(Rev.10/2014) Page 1 of I