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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> Exchange CIO CtileRNfirtr TIN brellliml <br /> of Child Abuse of North Carolina, Inc. <br /> 9 • <br /> Date o v. 1/24/2017 <br /> To State Agency Heal' iii1.-r.cfP west Boulevard <br /> Winston-Salem,N.C.27105 <br /> (336)748-9028 FAX(336)748-9030 <br /> Certification: www.exchangescan.org <br /> We certify that the NF6,:ariiail*:tigqliaiikirtkhvtTaraO3FMViid:ki'tn.,ti: <br /> (Organization's Name]does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, <br /> at the federal, State, or local level. We further understand that any person who makes a <br /> false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense <br /> punishable as provided by N.C.G.S. 143C-10-1. <br /> Sworn Statement: <br /> Jennifer L,,,;martin[name of Board Chair] and G-o ge'Bryan (name of Second Authorizing Official] <br /> being duly sworn, say that we are the Board Chair and' 'gc:.7*IYO0tN,c,Ok(Title of the Second <br /> Authorizing Official], respectively,____ <br /> of tiaiiii-Ora6reiltdi,f4'01'6`P*6117r6"eitf:EtiktiWiraffiriiiL[Organization's Name]of <br /> Wirl*iii5aLervi[City]in the State of NC[State]; and that the foregoing certification is true, <br /> accurate and complete to the best of our knowledge and was made and subscribed by us. <br /> We also acknowledge and understand that any misuse of State funds will be reported to <br /> the appropriate authorities for further action. <br /> 7 Jaime E Ledbetter <br /> NOTARY PUBLIC <br /> ;•;LetriFh..r Signa 4111•P'' Date <br /> m* Forsyth County, NC <br /> • I•t- 17 <br /> Seco Authorizing Offici., 4a/re Date <br /> ON `Alma° glAsioA <br /> ' <br /> .1ztct9y; onanci ALIVION <br /> Title of Second Authorizing Official <br /> JellecIPel 3 ewler <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> A-. :2 41 <br /> My Commission Expires: 10// 72-C) <br /> (Nothy Signature and Seal! <br /> If there are any questions, please contact the Department of Public Safety that funded the program <br /> agreement. If needed, you may contact the North Carolina Office of State Budget and Management, <br /> NCGrants@osbm.nc.gov- (919) 807-4795 <br /> 1 G.S. 105-243.1 defines: "Overdue tax debt. Any part of a tax debt that remains unpaid 90 days or more after <br /> the notice of final assessment was mailed to the taxpayer.The term does not include a tax debt, however, if <br /> the taxpayer entered into an installment agreement for the tax debt under G.5. 105-237 within 90 days after <br /> ,EtNCD Fo ( \\ uty 1,7005 Revised July 18,2006,7/07,9/08,7/10 <br /> j. is form i 0 ,.-ctronic format (Microsoft Word document)at http://ncarts.oreigrants/grant-forms/ <br /> 4kao, <br /> National Exchange Club <br /> Foundation For The Partially funded by <br /> Prevention of Child Abuse United Way <br />