2018-585-E DSS - Senior Care-Solyts adult care

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DocuSign Envelope ID:AA69FB9A-1A2E-426C-AC90-FAA292CFBF41 A.TTACEMLN I`E OVERDUE TAXES Orange County Department of Social Services Instructions: Grantee/Provider should complete this certification for all funds received.Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form trust be provided to the County Department of Social Services. Senior Care of Orange County,Inc. Tune 29,2018 To: Orange County Department of Social Services Certification: We certify that Senior Care of Orange County,Inc.does not have any overdue tax debts,as defined by N.C.G.S. 105-243.11,at the federal, State,or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c)is guilty of a criminal offense punishable as provided by N.C.G.S. 1430-10-1(b). Sworn Statement: David Wilkerson and Nancy Espersom being duly sworn,say that we are the Board President and Treasurer respectively, of Senior Care of Orange County,Inc.of Hillsborough in the State of North Carolina and that the foregoing certification is true,accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State fXuds will be rep ed to the appropriate authorities for further action. a Boar resider Treasurer Sworn to and subscribed before me on the day of the date of said certification. 'Qpmmissioxt Expires: Vrta123 ature an Seal)eA# R e*Y►Y'ti 6%1 N 0.r y> Zy "G.S. 105-243.1 defines:Overdue tax debt.�:: '} pa�ditt4�ebt t��cmains unpaid 90 days or more after the notice offinal assessment was mailed to the tak}x The term doe. meiucle a tax dent,however,if tha taxpayer entered into an installment agreement For the ti to01 g8rt +N'Ob7 within 90 days after the notice of final assessment was mailed and has not failed to make a irf pRymAixwq'ue under the installment agreernerut." Overdue Taxes—(07108) Page I of I