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DocuSign Envelope ID: E51E535C-F71B-44A8-86D6-2EAB7FFA6A81 <br /> 1 <br /> I 1 <br /> I 1 <br /> • . 1 <br /> I i <br /> I I <br /> PERSONALIZED PATIENT HOME ASSISTANCE <br /> 109 CONCORD DRIVE <br /> CHAPEL HILL,NC 27516 <br /> ) <br /> TO: ORANGE COUNTY <br /> , <br /> FROM; Dorothea Farrington,Owner <br /> i <br /> DATE: June 23;2017 <br /> )11 <br /> OVERDUE TAXES CERTIFICATION <br /> . . <br /> WE CERTIFY THAT PERSONALIZED PATIENT HOME ASSISTANCE DOES NOT HAVE ANY <br /> OVERDUE TAX DEBTS AS DEFINED BY N.C.G.S.105-243.1 AT THE STATE,FEDERAL,OR LOCAL 1 <br /> LEVEL. WE FURTHER UNDERSTAND THAT ANY PERSON WHO MAKES A FALSE STATEMENT IN <br /> VIOLATION OF N.C,G.S.IS GUILTY OF A CRIMINAL OFFENSE PUNISHABLEBY N.C.G.S,143C- . <br /> 10-1(b). <br /> ! <br /> SWORN STATEMENT: <br /> . f <br /> I <br /> I I,DOROTHEA FARRINGTON BEING DULY SWORN,STATE THAT I AM THE OWNER OF <br /> I <br /> PERSONALIZED PATIENT HOME ASSISTANCE IN THE STATE OF NC AND THAT THE <br /> ; FOREGOING CERTIFICATION IS TRUE. <br /> ! <br /> 1 <br /> li <br /> i <br /> . 1 <br /> , <br /> i; <br /> SIGNATURE odomeou,04. <br /> I <br /> , I <br /> .z. <br /> e... <br /> .... 1, •.,1.r. . <br /> il <br /> i DATE .3.77: , ..p•.,c_,z <br /> : >; <br /> ; z - -r!, <br /> 1-0 ,.Me <br /> ■Il <br /> 1, i‘A.• <9 , i c6;.2.• <br /> 11 <br /> SI,c6" ' <br /> .. c <br /> , 6 <br /> ,,, ,,,v ..,G. .0. <br /> I.' <br /> IY•1 4'00 <br /> 11 <br /> Henry Clinton Jones <br /> 1, <br /> • <br /> Notary Public :.....,ii co an. su :-..,.‘. ..t.-.... be ,.'ir; .1v: , <br /> ',..'■__....,,, <br /> . <br /> l' <br /> ,1 <br /> Orange Co., NC <br /> k <br /> . <br /> • <br /> „ <br /> M ' Commission expires Li-zcl— .2.6-2.- .- <br /> 11. . <br /> it <br /> .23 . <br /> &man tp and isubrObari balers firi Via. <br /> 1, <br /> day ciIi714 '`-'•( -- ' <br /> ,. <br /> .; <br /> Vkitnema my hand and official seal. <br /> . : - --.)--- <br /> I <br /> / i <br /> I/ !! 11 <br />