2021-169-E Health-NC DHHS FY22 consolidated agreement

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DocuSign Envelope ID:B749018F-351A-4D6F-9FC5-C2EB21856524 Consolidated Agreement FY22 Page 27 of 27 ATTACHMENT D STATE CERTIFICATIONS Contractor Certifications Required by North Carolina Law Instructions:The person who signs this document should read the text of the statutes and Executive Order listed below and consult with counsel and other knowledgeable persons before signing.The text of each North Carolina General Statutes and of the Executive Order can be found online at: • Article 2 of Chapter 64: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFByArticle/Chapter_64/Article_2.pdf • G.S. 133-32: http://www.ncga.state.nc.us/gascripts/statutes/statutelookup.pl?statute=133-32 • Executive Order No.24(Perdue,Gov.,Oct. 1,2009): http://www.ethicscommission.nc.gov/library/Pdfs/Laws/E024.pdf • G.S. 105-164.8(b): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_105/GS_105-164.8.pdf • G.S. 143-48.5: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter 143/GS_143-48.5.html • G.S. 143-59.1: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_143/GS_143-59.l.pdf • G.S. 143-59.2: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_143/GS_143-59.2.pdf • G.S. 143-133.3: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/HTML/BySection/Chapter 143/GS_143-133.3.html • G.S. 143B-139.6C: http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter_143B/GS_143B-139.6C.pdf Certifications (1) Pursuant to G.S. 133-32 and Executive Order No. 24 country"as set forth in G.S. 143-59.1(c)(2)after (Perdue, Gov., Oct. 1, 2009), the undersigned hereby December 31, 2001 but the United States is not certifies that the Contractor named below is in the principal market for the public trading of the compliance with, and has not violated,the provisions of stock of the corporation incorporated in the tax either said statute or Executive Order. haven country. (2) Pursuant to G.S. 143-48.5 and G.S. 143-133.3, the (4) Pursuant to G.S. 143-59.2(b), the undersigned hereby undersigned hereby certifies that the Contractor named certifies that none of the Contractor's officers,directors, below, and the Contractor's subcontractors, complies or owners (if the Contractor is an unincorporated with the requirements of Article 2 of Chapter 64 of the business entity) has been convicted of any violation of NC General Statutes,including the requirement for each Chapter 78A of the General Statutes or the Securities Act employer with more than 25 employees in North of 1933 or the Securities Exchange Act of 1934 within Carolina to verify the work authorization of its 10 years immediately prior to the date of the bid employees through the federal E-Verify system." E- solicitation. Verify System Link: www.uscis.gov (5) Pursuant to G.S.143B-139.6C,the undersigned hereby (3) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor will not use a former certifies that the Contractor named below is not an employee,as defined by G.S. 143B-139.6C(d)(2), of the "ineligible Contractor" as set forth in G.S. 143-59.1(a) North Carolina Department of Health and Human because: Services in the administration of a contract with the (a) Neither the Contractor nor any of its affiliates has Department in violation of G.S. 143B-139.6C and that a refused to collect the use tax levied under Article 5 violation of that statute shall void the Agreement. of Chapter 105 of the General Statutes on its sales (6) The undersigned hereby certifies further that: delivered to North Carolina when the sales met one (a) He or she is a duly authorized representative of the or more of the conditions of G.S. 105-164.8(b);and Contractor named below; (b) [check one of the following boxes] (b) He or she is authorized to make, and does hereby ❑ Neither the Contractor nor any of its affiliates make, the foregoing certifications on behalf of the has incorporated or reincorporated in a "tax Contractor; and haven country" as set forth in G.S. 143- (c) He or she understands that any person who 59.1(c)(2)after December 31,2001; or knowingly submits a false certification in response ❑ The Contractor or one of its affiliates has to the requirements of G.S. 143-59.1and -59.2 shall incorporated or reincorporated in a"tax haven be guilty of a Class I felony. Contractor's Name: Orange County Health Department DocuSigned by: Contractor's 3/16/2 021 Authorized Agent: Signature Date 30uirita aFStewart Orange County Health Department Printed Name D-oe S-g'�Je-d-by Title Witness: Signature txi,�rw.t,, Date 3/15/2021 Kimberlee Quatrone BE77D91B9275412... Printed Name Title Business Officer The witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter.