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DocuSign Envelope ID: EAAlB08E-4226-45A4-818B-A35B979DD90C <br /> Contract#68-2014 <br /> Senior Care of Orange County,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(b), 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. 143-59.1 and-59.2 shall be guilty of a Class I felony. <br /> senior care of orage county; inc. <br /> DocuSigne y: <br /> Contractor s Name <br /> g"A -- 7/20/2015 <br /> €71151152 .®aaa... -- <br /> Signature of Contractor's Authorized Agent Date <br /> Alvonia Baldwin Director <br /> Printe Ne-oa tractor's Authorized Agent Title <br /> vt��tvy vice. <br /> 61BFBEa81a56447 office Manager <br /> Signature of Witness Title <br /> Kristin Price 7/20/2015 <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 />