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STATE OF NORTH CAROLINA <br />COUNTY SALES AND USE TAX REPORT <br />SUMMARY TOTALS AND CERTIFICATION <br /> <br /> <br />CONTRACTOR: Page __1____ of ______ <br /> <br />PROJECT: FOR PERIOD: <br /> <br /> <br /> TOTAL FOR <br />COUNTY OF: <br /> <br />TOTAL FOR <br />COUNTY OF: <br />TOTAL FOR <br />COUNTY OF: <br />TOTAL FOR <br />COUNTY OF: <br />TOTAL FOR <br />COUNTY OF: <br />TOTAL FOR <br />COUNTY OF: <br />TOTAL <br />ALL COUNTIES <br />CONTRACTOR <br />SUBCONTRACTOR(S)* <br />COUNTY TOTAL <br /> <br />* Attach subcontractor(s) report(s) <br />** Must balance with Detail Sheet(s) <br /> <br />I certify that the above figures do not include any tax paid on supplies, tools and equipment which were used to perform this contract <br />and only includes those building materials, supplies, fixtures and equipment which actually became a part of or annexed to th e building <br />or structure. I certify that, to the best o f my knowledge, the information provided here is true, correct, and complete. <br /> <br />Sworn to and subscribed before me, <br /> <br />This the _______ day of _____________, 20____ <br /> <br /> <br /> Signed <br />Notary Public <br /> <br />My Commission Expires: Print or Type Name of Above <br /> <br />Seal NOTE: <br /> This certified statement may be subject to audit. <br />DocuSign Envelope ID: A9A4637A-BE59-4285-99BE-D253C29FA836