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DocuSign Envelope ID: 1582AE24-D793-4A66-9311-4472000BOEC3 <br /> Contract#68-2004 <br /> Personalized Patient Home Assistance, Inc. <br /> more of the conditions of G.S. 105-164.8(b); and <br /> (b) [check one of the following boxes] <br /> ❑ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven <br /> country"as set forth in G.S. 143-59.1(c)(2)after December 31, 2001; or <br /> ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country" <br /> as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the <br /> principal market for the public trading of the stock of the corporation incorporated in the tax <br /> haven country. <br /> (3) Pursuant to G.S. 143-59.2(h), the undersigned hereby certifies that none of the Contractor's officers, directors, <br /> or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter <br /> 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years <br /> immediately prior to the date of the bid solicitation. <br /> (4) The undersigned hereby certifies further that: <br /> (a) He or she is a duly authorized representative of the Contractor named below; <br /> (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the <br /> Contractor; and <br /> (c) He or she understands that any person who knowingly submits a false certification in response to the <br /> requirements of G.S. 143-59.1and -59.2 shall be guilty of a Class I felony. <br /> Personalized Patient Home Assistance <br /> Contra IT=by: <br /> F .VyUqbin, 7/14/2015 <br /> Signature o ontractor's Authorized Agent Date <br /> Dorothea Farrington Agency director <br /> Printe mes tractor's Authorized Agent Title <br /> tUA AVVIIti> blil <br /> Attorney <br /> 'FE 25E-1 EJ F2" ... <br /> Signature of Witness Title <br /> carmilla Farrington 7/14/2015 <br /> Printed Name of Witness Date <br /> The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date <br /> this document immediately thereafter. <br /> Contractor Certifications Required by North Carolina Law Page 2 of 2 <br />