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

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DocuSign Envelope ID:AA69FB9A-1A2E-426C-AC90-FAA292CFBF41 Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105-164.8(b); and (b) [check one of the following boxes] ❑ Neither the Contractor nor any of its affiliates has incorporated or reincorporated in a"tax haven country"as set forth in G.S. 143-59.1(c)(2)after December 31,2001;or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a"tax haven country" as set forth in G.S. 143-59.1(c)(2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. (3) Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners(if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. (4) The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and (c) He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59.land-59.2 shall be guilty of a Class I felony. (5) Pursuant to the Orange County Living Wage Contractor's Policy: (a) The undersigned certifies that the Contractor pays the employees who perform services under this contract a living wage (in Orange County currently $14.25 per/hr.) Check here ® if contractor pays employees performing under this contract a living wage. If Contractor does not pay employees a living wage,what is the wage that employees performing services under this contract paid Senior Care of Orange County,Inc. o Nm e8/24/2018 e o cintractor's Authorized Agent Date Swayzene Riggsbee Executive Director r,�}�Pe of Contractor's Authorized Agent Title UVS aw Program Coordinator Signature o Witness Title Ursula Barr 9/20/2018 Printed Name of Witness Date The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter. Contractor Certifications Required by North Carolina.Law Page 2 of 3 revised May 30,2018