2019-632-E DSS - Senior Care of OC adult day care

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DocuSign Envelope ID: 179DC6FB-73BA-4F64-A513-C8AB2B7D864F ATTACHMENT E OVERDUE TAXES Orange County Department of Social Services Instructions: Grantee/Provider should complete this certification for all funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form must be provided to the County Department of Social Services. Senior Care of Orange County,Inc. June 6,2019 To: Orange County Department of Social Services Certification: We certify that Senior Care of Orange County,Inc. does not have any overdue tax debts,as defined by N.C.G.S. 105-243.1% at the federal, State,or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c)is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1(b). Sworn Statement: David Wilkerson and Ann Burton being duly sworn, say that we are the Board President and Treasurer respectively, of Senior Care of Orange County,Inc. of Hillsborough in the State of North Carolina and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. 1 Boar esident Secretary Sworn to and subscribed before me on the day of the date of said certification. �5i�+��nnr+rnr+r, aSANNE toAk My Commission Expires: �r gpatu kud Seal) '> z_ ge. 105-24.k.11¢�nes:overdue tax debt.—Any pant of a tax debt that remains unpaid 90 days or more after the nt�e oWti�s4sment was mailed to the taxpayer.The term does not include a tax debt,however,if the taxpayer enteredrmfo an installment agreement for the tax debt under G.S. 105-237 within 90 days after the notice of fins assessment was mailed and has not failed to make any payments due under the installment agreement." Overdue Taxes—(07/08) Page 1 of 1