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Limited Waiver of Confidentiality <br />Unemployment Tax and Wage Records <br />BUILDING REUSE PROGRAM – Revision #3 <br />EXHIBIT G <br /> <br />2020-025-3201-2587 <br /> <br />Waiver of Confidentiality - 1 <br /> <br /> <br />Name of Taxpayer <br /> <br />Address: <br /> <br />City: State: Zip: Phone: <br /> <br />NC Unemployment Insurance Acct #: Fed Tax ID #: <br /> <br />I hereby waive any right to confidentiality, as found in N.C.G.S. 96-4 or otherwise, for <br />the limited purpose of authorizing disclosure of certain information contained in the quarterly <br />unemployment insurance tax records of the above-named taxpayer (hereinafter, “Company”) <br />filed with the Division of Employment Security (“DES”) of the North Carolina Department of <br />Commerce to Orange County (“Governmental Unit”) and to the employees of the Rural <br />Economic Division of the North Carolina Department of Commerce (“Rural Division”) and <br />members of the North Carolina Rural Infrastructure Authority (“Rural Authority”) for the limited <br />purpose of evaluating the issuance of and, in the event of such issuance, administering and <br />ensuring compliance with, a grant and loan pursuant to N.C.G.S. 143B-472.127 and .128. <br /> <br />I recognize that DES is authorized to provide this information to the public officials of <br />the Governmental Unit, the Rural Division and the Rural Authority in the performance of their <br />public duties and that the verification of employment information for the purpose of <br />administering the grant and loan at issue is within the scope of the public duties of the <br />Governmental Unit, the Rural Division and the Rural Authority. I hereby authorize DES to <br />disclose information contained in the Company’s quarterly unemployment insurance tax records <br />(the NCUI-101 or successor form) to the Governmental Unit, the Rural Division and/or the <br />Authority for these purposes. <br /> <br />I recognize that unemployment insurance tax information provided in the aggregate to <br />DES and disclosed to the Governmental Unit, the Rural Division and/or the Authority, and the <br />Company’s aggregated tax and wage information provided to or otherwise in possession of the <br />Governmental Unit, the Rural Division and/or the Authority, may be treated as public <br />information. This waiver is not intended to release the Governmental Unit, the Rural Division <br />and/or the Authority from any obligation they may have under North Carolina law to maintain <br />the confidentiality of any and all information which could reveal or permit someone to ascertain <br />the identity of any individual employee or that employee’s line item unemployment insurance <br />tax or other tax or wage information. <br /> <br />Signature Chief Financial Officer or Other Authorized Company Official <br /> <br /> , <br />Print Name Title <br /> <br /> <br /> <br />37