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19 <br /> ATTACHMENT E <br /> OVERDUE TAXES <br /> Orange County Department of Social Services <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 /> Entity's Letterhead <br /> [Date of Certification(mmddyyyy)] <br /> To: Orange County Department of Social Services <br /> Certification: <br /> We certify that the [insert organization's name] does not have any overdue tax debts,as <br /> defined by N.C.G.S. 105-243.11,at the federal, State,or local level. We further understand that <br /> any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c)is guilty of a <br /> criminal offense punishable as provided by N.C.G.S. 143C-10-1(b). <br /> Sworn Statement: <br /> [Name of Board Chair] and [Name of Second Authorizing Official]being duly sworn, say that we <br /> are the Board Chair and [Title of the Second Authorizing Official],respectively,of[insert name <br /> of organization] of[City] in the State of[Name of State]; 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 /> Board Chair <br /> [Title of Second Authorizing Official] <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> My Commission Expires: <br /> (Notary Signature and Seal) <br /> 1 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 fmal 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 fmal <br /> assessment was mailed and has not failed to make any payments due under the installment agreement." <br /> Overdue Taxes—(07/08) Page 1 of 1 <br />