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DocuSign Envelope ID: FB3E3E71-F2B8-41 IIA-81 C9-1392ACCOFE1 1 <br /> Contract#68-2025 <br /> more of the conditions of G.S. 105-164.8(b); and The Community Empowerment Fund <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 /> El 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 1.934 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 /> Community Empowerment Fund <br /> IS1911—uy. <br /> Contractor' Ida me <br /> 1/25/2016 <br /> Signature of Contractor's Authorized Agent Date <br /> Maggie West Program coordinator <br /> Printed Na e r `[ractgrthorized Agent Title <br /> operations coordinator <br /> Signature of Witness Title <br /> 3onathan 1/26/2016 <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 oft <br />