2018-799-E DSS - Charles House adult day care services

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DocuSign Envelope ID:6D5F41 E3-E7E2-4D6C-BE76-951 E8674450E 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] [1 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 fin then 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 snake, 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 1 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 (inOrange 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 Charles House association DocuSigned by: 11C rA� W"tlr 11/5/2018 6F281B385FS64BB... - aignarure or t ontractor's Authorized Agent Bate Paul Klever Executive Director [PA084AAAA20A443C oocuSignedby: Contractor's Authorizeed Agent "title au klr Executive Director ... Signature or witness Title: Paul Klever 12/3/2018 Printed Marne 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