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DocuSign Envelope ID:9E1 F9021-C474-4807-8F93-1 C616BEBDEF1 <br /> *****Contractor Vendor or Bidder—Return This Form With All Other Re•uired Documentation***** <br /> IRAN DIVESTMENT ACT CERTIFICATION REQUIRED BY N.C.G.S. <br /> 143C-6A-5(a) <br /> Name of Contractor,Vendor or Bidder: 1116 NI" <br /> As of the date listed below,the contractor, vendor or bidder listed above, and all subcontractors <br /> utilized by the contractor,vendor or bidder listed above, is not listed on the Final Divestment <br /> List created by the State Treasurer pursuant to N.C.G.S. 143-6A-4. <br /> The undersigned hereby certifies that he or she is authorized by the contractor,vendor or bidder <br /> listed above to make the foregoing statement. <br /> di <br /> �� JVYO. +'ms nmy w 41 <br /> Sigyafure d' Date <br /> �/ n, � <br /> III <br /> 1. <br /> m�. , w <br /> Printed Name Title <br /> Notes to persons signing this form: <br /> N.C.G.S. 143C-6A-5(a)requires this certification for bids or contracts with the State of North <br /> Carolina, a North Carolina local government, or any other political subdivision of the State of <br /> North Carolina. The certification is required at the following times: <br /> ❑When a bid is submitted <br /> C When a contract is entered into (if the certification was not already made when the vendor <br /> made its bid) <br /> ❑When a contract is renewed or assigned <br /> N.C.G.S. 143C-6A-5(b)requires that contractors with the State, a North Carolina local <br /> government, or any other political subdivision of the State of North Carolina must not utilize <br /> any subcontractor found on the State Treasurer's Final Divestment List. The State Treasurer's <br /> Final Divestment List can be found on the State Treasurer's website at the address <br /> wWW.nctreasurer,com/l:ran and will be updated every 180 days. <br /> *****Contractor,Vendor or Bidder—Return This Form With All Other Required Documentation***** <br />