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DocuSign Envelope ID: 1582AE24-D793-4A66-9311-4472000BOEC3 <br /> Contract#68-2044 <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 Department of Social Services. <br /> Ye i on(!s <br /> o mmadmy)] <br /> To: Orange County Department of Social Services <br /> Certification: � ti� <br /> We certify that the [insert organid7tion's name] does not have any overdue tax debts, as <br /> defined by N.C.G.S. 105-243.1',at the federal, State, or local level. We further understand that <br /> any person who makes a false statement in violation ofN.C.G.S. 143C-6-23(c) is guilty of a <br /> criminal offense punishable as provided by MC.G.S. 143C-10-1(b). <br /> Sworn Statement: <br /> De R.&. Yin at. �4pow► <br /> [Name of ` ]an . ame of vial]being duly swo say t__haa�t,w�� p <br /> e the d g Official],respectively,of� � <br /> o e State of[N ];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 action. <br /> 3�I/lI y1 <br /> .r Ow r JPL *''' aY C <br /> _e;a Car �,• � 1- <br /> [Title of Second Authorizing Official] f 'fit <br /> >.� <br /> SvKorn to and subscribed before me on the day of the date of said certification. % �'�:�'& <br /> ��°rrrletS� <br /> My Commission Expires: <br /> tary 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—(07108) Page 1 of 1 <br />