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oc u SniEnLive I 08?LID 9tBJE925674,9,5, :1p,,_9,:13,C,4 p_E n 1 9199678269 TO 91'364433E2 P.1 <br /> OVERDUE TAXES <br /> PERSONALIZED PATIENTOME ASSISTANCE <br /> JULY 1,2016 <br /> TO: ORANGE COUNTY D4 AND ORANGE COUN <br /> DEPT.ON AGING <br /> FROM: Dorothea Farrington <br /> CERTIFICATION; <br /> WE CERTIFY THAT PERSONALIZED PATIENT HOMIt <br /> ASSISTANE DOES NOT HAVE ANY OVERSUE TAX <br /> DEBTS AS DEFINED BY N.C.G.S.105-243.1 AT THE <br /> STATE,FEDERAL,OR°CAI;LEVEL WE FURTHER <br /> UNDERSTAND THAT ANY PERSON WHO MAKE5 A <br /> FALSE STATEMENT IN VIOLATION OF N.0 GiS.IS <br /> GUILTY OF A CRIMINAL OFFENSE PUNISHABLE B <br /> N.0 .5 143C-10-1(b), <br /> SWORN STATEMENET: <br /> DOROTHEA FARRINGTON BEING DULY SWORN, <br /> STATE THAT I AM THE 0,,IER OF PERSONALIZED <br /> PATIENT HOME ASST.IN THE STATE OF NC AND <br /> THAT THE FOREGOINGCERTIFICATION IF TRUE. <br /> WE UNDERSTAND THAT AN MISUSE OF STATE <br /> FUNDS WILL BE REPORT TO THE APPRIPRIAT <br /> AUTHORITIES FOR FURTH R ACTION, <br /> Dorothea Farrington,op ner <br /> toonsit, <br /> S4'!'; :11).20 •• I <br /> f.0/ <br /> HenY linton Jones <br /> Si1-k-x.t, ice,1 <br /> • %. s 4 <br /> -Lori z. <br /> 04N "" ,45-,so <br /> ado ry Public <br /> Ora ;9 Co NC <br /> MS/Coriirtigh <br /> expires Do. <br />