2016-491-E DSS - Charles House Association for adult day care

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000vSign Envelope ID: n1Ce00001185-4roA~^CrB-8C1rurr0013r more of the conditions of G.S. 105-164.8(h); and (b) [check one of the foll i boxes] � Neither the Contractor nor any of its affiliates has incorporated or re inu"tax have country" as set forth iu143-59.1(c)<2) u��rl)�o�mbcr3l 200L� pr G.S.� ` , The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country' as set forth in G.S. 143'59.l(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the la,. haven country. (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors or owners (if{b� (�ou�nxctoriaouuoiuuorporu1�dbuuiu�yu �nl�k/) huoh��u000vic�c� o�nnyvinla1inun�(�hup�� (if entity) 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 year immediately prior to the date of the bid solicitation. (4) The undersigned hereby certifies further that: (a) I-Ic or she is a duly authorized representative of the Contractor named below, (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and , (o) He or she understands that any person who knowingly submits a false certification in response to the requirements oyG.8. 143'59.luud 59.2 shall hc guilty wfa Class lfelony. (5) Pursuant to the Orange County Living Wage Contractor's Policy: (a) The undersigned certifies that the Contractor pays the employees who perform services under this contract ~� living wage (in Orange County currently $13.l5 per/hr.) Check here if contractor pays employee, ' j performing under this contract u living vva#e. l[Con�uotmr does not pay employees u living vxagc,v�bat 'sth~ wage that employees performing services under this contract pale charles House Association - -- ' Contractor's HY ^/ u^ PAUL 8/24/2016 �� Signature nf`"..tf-sarig-TrT7TdtborizedAgent Date Paul nl eve r Executive Director Printed N"C77~°`�^ Authorized Agent Title ` °A ,0 Program Administrator ww+2C- Signature of Witness Title chuck Fleming 8/24/2016 Printed Name of Witness Date The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and dal this document immediately thereafter. Contractor Certificatio s Required by North Carolina Law Page 2 of