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DocuSign Envelope ID: o240er38-3r84-4*4e'e0e8-C4r5eAC37487 <br /> more of the conditions of U.S. 105-164.8(b); and <br /> (b) [check one of the following boxes] <br /> F� Neither bcCo�mcNzuor �� ofhaN�|��sk� � or � o '�� hm- ' <br /> __ country" uu set forth inG.S. [43'5g.l(o) (2)after December 31, 208l; mr I <br /> l The Contractor or one ot'its affiliates has incorporated or reincorporated in a -tax haven count'.`1 <br /> " <br /> as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is <br /> not t e <br /> principal market for the public trading of the stock of the corporation incorporated in the t~1` <br /> haven country. <br /> (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, director., <br /> or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapt.lr <br /> 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 yea s <br /> immediately prior to the date of the bid solicitation. <br /> . <br /> (4) Theundeoi8nedbere6vccrtificxfudbertbut: <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 t e <br /> Contractor; and <br /> (o) He or she understands that any person who knowingly submits a false certification in response to ti e <br /> requirements of G.S. 143'59.1and '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 cmo(ractlu <br /> living wage (in Orange County currently $13.15 peribr.) Check here I if contractor pays enup|oyo(s <br /> performing under this contract a living wage. If Contractor does not pay employees a living wage, v/hat is t e <br /> wage that employees performing services under this contract paid <br /> -- — -- -- -- | <br /> KAH care' LLC <br /> Signed by. <br /> Coo <br /> 7/18/2016 <br /> Signature of Contractor's Authorized Agent Date <br /> Ken Helmuth owner <br /> Pr in r`s Authorized Agent <br /> C w~ <br /> zu^o^�u���� Title <br /> o <br /> Di rector o r of operations <br /> Signature nfWitness Title <br /> Pam Williamson 7/20/2016 <br /> Printed Name ofWitness Date <br /> The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and d, e <br /> this document immediately thereafter. <br /> Contractor Certifications Required by North Carolina Law Page 2n 2 <br /> 1 <br />