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DocuSign Envelope ID:456CB831-89E2-409B-871 5-A71 C362353A4 <br /> DocuSign Envelope ID:EAA1B08E-4226-45A4-818B-A3569790090C <br /> Contract 1/68-2014 <br /> Senior Care of Orange County.Inc, <br /> ATTACHMENT it <br /> OVERDUE TAXES <br /> Orange County Deportment 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 /> Florence Gray Sottys Adult Day Health Program <br /> Operated by: Senior core of Orange Coimty,Inc. <br /> 105 Meadowland Drive <br /> Hillsborough,North Carolina 27278 <br /> 06/24/2015 <br /> To Orange County Department of Social Services <br /> Certification: <br /> We certify that the Senior Core of Orange County'b;c does not have any overdue tax debts,as <br /> defined by N.C.0.5, I 05-243,1E,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-4-23(c)is guilty of a <br /> criminal offense punishable as provided by N.C.O.S, 143C-10-1(b), <br /> Sworn Statement: <br /> John Hammond and David Wilkerson]being duly sworn,say that we are the Board Chair and <br /> Treasurer,respectively,of Seuior Care of Orange County; Inc of Hillsborough in the State of <br /> North Carolina;and that the foregoing certification is true,accurate ancicoinplete to the best of <br /> our knowledge and was made and subscribed by us. We also acknowledge and understand that <br /> any misuse of State funds will be reported to the appropriate authorities for further action. <br /> //c/i66. )144-te4,7451x <br /> a, 'd Chi <br /> • .1 • :7 <br /> 0g <br /> re; rer <br /> 94 <br /> Sworn to and subscribed before me on the day of the date of said certification. vv• <br /> ''',0111111111 L"''' <br /> .416, 1.-1.KAA'.•1/4 My Commission Expires:Fe ) 84 <br /> otary ignature and Seal) <br /> a;odivni <br /> G.S. 105-243.1 defines:Overdue tax debt.—Any part of a tax debt that manilas unpaid 90 days or mere alter the <br /> notice of tinal assessment was nailed 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 a& 105-237 within 90 days after the native of ling <br /> assessment was mailed and hes not tailed to make any payments due under the installment agreement," <br /> Overdue Taxes—(07/08) Page 1 of <br />