Agenda - 06-23-2004-5d - Laserfiche WebLink

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North Carolina State Firemen's Association P.O. Box 188 3 Farmville, NC 27878 800 - 253 -4733 2003 ANNUAL CERTIFICATION OF FIREMEN North Carolina General Statute 58 -86 -25 requires that all certified fire departments submit a complete roster of its eligible firemen annually This certified list determines eligibility for the $50,000 line -of -duty death benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this information is violation of G.S. 58 -86 -25 and will automatically result in a loss or reduction of benefits. REPORT BY FIRE DEPARTMENT CHIEF As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible firemen, within the definition contained in North Carolina General Statute 58- 86 -25. Name of Fire Department lti A K[Ge L -DUNTy h12E WW614ALS 0 MCE Fire Department "`Mailing Address � C) . 6t City �tLCS►goPMG[4 State �C Zip Code a�a� Name of Fire Chief ! Y I l IPip m � (Please mint or tvne) Signature of Fire Date �—�% "Q� Daytime Telephone_ 0119) County A71G6 CERTIFICATION BY GOVERNING BODY Pursuant to G S, 58- 86 -25, the governing body of afire department operated by (i) a county is the county board of commissioners, (ii) a city is the city council, (iii) a sanitary district is the sanitary district board, (iv) a corporation, whether profit or nonprofit, is the corporation's board of directors and (v) any other entity is that group designated by the board Therefore, in our capacity as the governing body of the above -named fire department, we certify and find that the attached roster is a valid and accurate list of all eligible firemen in accordance with G.S 58- 86 -25. Name of Governing Name of Governing Body Official BA&2 ( ACO S ease print or type) Authorized Title C PA I P) Date (p 3 — Q) Daytime Telephone-(!Q14 _7 3Z ` S A 1 S Oo,�LS