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Signature Card <br /> r <br /> CONTRACT& FINANCIAL DOCUMENTS <br /> INSTRUCTIONS: Please read and fill in the required information to the right of each field where applicable. Provide the <br /> requested printed and written signatures (in Blue Ink) of agency representatives in the designated areas. In the event <br /> the affixed signature(s) are no longer valid, a revised form must be submitted prior to processing any contractual <br /> documents or submitting"Request for Payments"or any other financial documents. <br /> SECTION I. <br /> Date: (a - - <br /> Legal Applicant Organization/Agency Name: <br /> Federal Tax Identification Number: - <br /> II. <br /> Certification: <br /> By affixing my signature below, I certify that person(s) identified are designated having legal authorization to sign on <br /> behalf of the organization named in Section I., above, for purposes of executing contractual documents and preparing, <br /> approving and executing all financial documents; including"Requests for Payments." I understand the legal implications <br /> of any and all misrepresentation, which include but are not limited to defrauding the State of North Carolina, and certify <br /> that the person signing below has full authority to execute this Agreement on behalf of the named organization. <br /> NON-GOVERNMENTAL ORGANIZATIONS ONLY <br /> Board Chair, Executive Director, etc. Financial Representative, Treasurer, etc. <br /> Print Name&Title: Print Name&Title: <br /> Signature: Signature: <br /> GOVERNMENTAL ENTITIES <br /> Authorized Governmental Official Chief Fiscal Officer <br /> Print e&Title: int Na e&Titl . �` <br /> & Aul 'O <br /> Signature: Signa r . <br /> NCDA&CS-Signature Card—NGO&Governmental Page 1 of 1 <br /> Rev 7/14 <br />