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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> Exchange C14 CJ'C "l'Cll.l brdmlion <br /> of Child Abuse of North Carolina,Inc. <br /> Date a -:`. 1/24/2017 <br /> To: State Agency Head l il*• f Wilgerrthwest Boulevard <br /> Winston-Saleiry N.C.27105 <br /> Certification: (336)748.9028 FAX(336)748.903D <br /> wFVw-exchangeseanmo g <br /> r'r_ , :.>:�-!3.1�!. v.�i4'�`,�•-5Y".aii��r� s'1���_F'1Hi�.'�]�f:�.".o�.�P'%;."='�y�: °iF?'^.T.�I::�c — �.?F. <br /> We certify that the 'et tinge;e cr at>veafel, a��;; h ? e err r limo C tX�ct abuse n C nc <br /> Or Name] <br /> C .� <br /> [Organization's 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 /> Jeri€er, gar ? name of Board Chair and vGea1' g �`: <br /> n ,:n�:^s.a.-•- ` � � ] .-w".•�� ��ra[name Of SeCd d AU thorizing Official] <br /> being duly sworn, say that we are the Board Chair and ec,ut uj treEta}[Title of the Second <br /> Authorizing Official], respectively <br /> ?4x'"!�:s? '"y` ?t�1-�;r;,•,�'T's!�:Pi�Fi �eiti"i:d�y,rr'�:,-u?�:y, "- ," a rLsll--y ��ay'„tlhs'-- <br /> of f E it a �l C n er a e� , eye t a ;a iNta tl t f. Enc(Organization's Name]of <br /> 19 �-ti*-•RF ki3Yr c <br /> i is b . alem[City]in the State of [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 /> °P--a"--- Jaime E Ledbetter <br /> Siena Date NOTARY PUBLIC <br /> Forsyth County, NC <br /> •lam . �� ! ` "• 17 <br /> Seco . Authorizing Official, in.ture Date ON Y� [�j/� <br /> .siA =4.� u>3w!.'.n 3s:n,�-n:i4 ON `AlunQ3 inASJOO <br /> EKe u5] cOprreq�to 01181141 ` <br /> Title of Second Authorizing Official � wie <br /> da�agpa'� � ea�l>~r <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> i ! . . '` <br /> My Commission Expires: l 0f/iSf L� <br /> (Not-ry Signature and Sear 1 <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 /> 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.S. 105-237 within 90 days after <br /> 1#NCD Fow;i:. A NV' Lily 1,2005 Revised July 18 2006 7/07 9/08;7110 <br /> i is form• r' '�. ectronic format(Microsoft Word document)at http://ncarts.org/grants/grant-forms/ <br /> y3' <br /> Nationa/Exchange Club <br /> Foundation For The Partially funded by <br /> Prevention of Child Abuse United Way <br />