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State Grant Certification — No Overdue Tax Debts or Conflicts of Intere <br />For • :1 <br />Date: 15/9" ko ( <br />Certification: <br />We certify that, <br />ig <br />Mark Dorosin - Oranae Coun <br />does not have <br />any overdue tax debts, as defined by N.C.G.S. 105 - 243.1, at the federal, State, or local level. I further <br />certify that I will not use funds awarded by this grant to satisfy any subsequent tax obligations. <br />Additionally, Mark Dorosin - Orange Cou <br />does not have any conflicts of interest with any employees of [Granting Agency], or any governing Board <br />as defined by North Carolina G.S.143- 6- 23(b)(c). I further understand that a false statement made is in <br />violation of N.C.G.S. 143 -6 -23 and such false statement would be a criminal offense punishable as <br />provided by N.C.G.S. 143C -10 -1. <br />Sworn Statement: <br />We Mark Dorosin - Orange County also acknowledge and understand that <br />any misuse of State funds will be reported to the appropriate authorities for further action. <br />Mark b1or`osin',C1Gr, Ba rd of County Commissioners <br />Name / Title <br />Sworn to and subscribed before me on the day of the date of said certification. <br />(Notary Signature and Seal) <br />Revised 2/11 <br />My Commission Expires: I/1 G' °ZlJ 1 <br />0 <br />