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Cv`~ <br />SAMPLE <br />ATTACHMENT E-2 <br />ANNUAL CERTIFICATION OF ACCOUNT BALANCE <br />ORGANIZATION NAME <br />ORGANIZATION FEDERAL ID NUMBER <br />The Grant Agreement(s) between the organization listed above and the North <br />Carolina Health and Wellness Trust Fund (HWTF) Section IV Grantee's Obligations, <br />paragraph H, subparagraph 6, stipulates the following: <br />Segregated Accounts - Grantee shall place all sums not immediately spent in a <br />segregated, interest bearing account that is fully insured for the maximum amount of <br />money that will be placed in the account, Grantee agrees that any interest accrued on <br />these sums along with any unspent funds remaining in the account shall belong to the <br />Commission at the conclusion of the Project.. <br />The undersigned hereby certifies that the ending balance of the segregated interest bearing account(s) <br />established pursuant to Section IV Grantee's Obligations, paragraph H, subpazagraph 6, of the <br />Grant Agreement, the monthly/quarterly statement provided by NAME OF FINANCIAL <br />INSTITUTION WHERE HWTF FUNDS ARE DEPOSITED dated DATE OF FINANCIAL <br />STATEMENT, is ENDING BALANCE FROM FINANCIAL STATEMENT. <br />SIGNATORY'S NAME <br />SIGNATORY'S TITLE <br />DATE SIGNED <br />33 <br />