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IRANDIVESTMENTACTCERTIFICATIONREQUIREDBYN.C.G.S. <br />143C-6A-5(a) <br />Name of Contractor, Vendor or Bidder: <br />As of the datelistedbelow, the contractor, vendor or bidder listedabove,andallsubcontractors <br />utilizedbythecontractor, vendor or bidder listed above, is not listed onthe FinalDivestment <br />Listcreatedby the StateTreasurer pursuant toN.C.G.S. 143-6A-4. <br />The undersigned herebycertifiesthathe or sheis authorized by the contractor, vendor orbidder <br />listed above tomake the foregoing statement. <br />Signature Date <br />PrintedNameTitle <br />Notesto persons signingthisform: <br />N.C.G.S. 143C-6A-5(a)requiresthiscertificationfor bids or contractswith the State ofNorth <br />Carolina, a North Carolina local government, or any other political subdivision ofthe State of <br />NorthCarolina.Thecertificationisrequiredat the following times: <br />