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000vSign Envelope ID: 8eE8uAu0-4CEE-4AC3eC41'ee34nE3nn1*4 <br /> more of the conditions of G.S. 105'104.8(b); and <br /> (b) [check one of the following boxes <br /> [— <br /> Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven <br /> country" as set forth in(].S. |4l'59.|kj(Z)after December 3\, Z00i; or <br /> | <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.l(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 /> , <br /> (c) He or she understands that any person who knowingly submits a false certification in response to the <br /> requirements of G.S. 143'59.1und -59.2 shall be guilty of a Class I felony. <br /> (5) Pursuant to the Orange County Living Wage Contractor's Policy: <br /> (a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a <br /> living wage (in Orange County currently $13.15 per/hr.) Check here if contractor pays employees <br /> performing under this contract a living wage. If Contractor does not pay employees a living wage, what is the <br /> wage that employees performing services under this contract paid <br /> personalized Patient Home Assistance <br /> Con r` <br /> /3vou�ov�uas— 7/13/2016 <br /> Signature of Contractor's Authorized Agent Date <br /> Dorothea Farrington <br /> Agency director <br /> Printed w" � ohrod Agent 'Fide��� � <br /> ' Attorney <br /> +4aA241o,20*24- <br /> Signature of Witness Title <br /> carmilla Farrington <br /> 7/13/2016 <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 dat <br /> this document immediately thereafter. <br /> Contractor Certifications Required 6 North [aro|i no Law Page 2 of 2 <br />__ __ <br />