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DocuSign Envelope ID:A4C13231-8323-41C4-8841-009EE8D11E71 <br /> ] _�lllbil 1: <br /> Samar Shawa <br /> 2409 Silver Lake Trail <br /> Raleigh,NC 27606 <br /> To: Orange County Department of Social Services <br /> Certification: <br /> I certify that I do not have any overdue tax debts, as defined by N.C.G.S. 105-243.1,at <br /> the federal, State, or local level. I further understand that any person who makes a false <br /> statement in violation of N.C.G.S. 143-6.2(b2) is guilty of a criminal offense punishable <br /> as provided by N.C.G.S. 143-34(b). <br /> Sworn Statement: <br /> 1, being duly sworn, say that I am Samar Shawa; and that the foregoing certification is <br /> true, accurate and complete to the best of my knowledge and was made and subscribed by <br /> me, I also acknowledge and understand that any misuse of State funds will be reported to <br /> the appropriate authorities for further action. <br /> S' a ure _ <br /> Sworn to ands��l oJ. <br /> ,, � �fo,emeonthe day ofp1U)"6, 20I . <br /> N �o <br /> G��: M Commission Ex Tres: J��i�a �• <br /> Y p ' <br /> (Notary Sig re lSIZ) <br /> ..OUNTq �, <br /> • S y C+yepnw � ` <br />