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4 <br /> NORTH CAROLINA DEPARTMENT OF AGRICULTURE AND CONSUMER SERVICES <br /> Steven W.Troxler,Commissioner <br /> Contract Check Off List for Grantee(Government State Funded) <br /> INSTRUCTIONS: Check the"Yes"boxes in the left column for the document titles that are being returned with the two signed, dated and witnessed copies of the <br /> contract, with signatures in blue ink. Be sure to include all the other documents specified in your contract package. If"No" has been checked off for you, that <br /> document is not required for this grant program or project. <br /> GRANTEE ORGANIZATION NAME: Orange County <br /> PROJECT TITLE/NAME: Poteat Family Farm Conservation Easement+/-110 Acres <br /> CONTRACT#: 22-086-4003 <br /> GO Entities Only Document Title Department Use- Grants and Contracts- <br /> Check One Box Documents Attached Documents Attached <br /> or On File or On File <br /> Yes No Contractual"Check Off List for Grantee Yes No Yes No <br /> Yes No Contract Cover To be signed,dated&witnessed Yes No Yes No <br /> Yes X No Attachment A-General Terms and Conditions-Govern ment/U n iversityYes X No Yes x No <br /> Yes No Attachment B-Scope of Work includes Timeline and Line Item Budget) Yes No Yes No <br /> Yes X No Attachment C-Certifications and Assurances Section Yes x No Yes x No <br /> Yes X No Attachment D-NCO enBook Supplemental Information Yes x No Yes x No <br /> Yes X No Attachment E-Signature Card Yes x No Yes x No <br /> Yes X No Attachment F-W-9 Tax Information I Yes I x I No Yes x I No <br /> Yes X No Attachment G-Vendor Electronic Payment Form Yes I x I NoYes x No <br /> Yes x No Yes x No Yes x No <br /> Yes x No Yes x No Yes x No <br /> Rev.6/17,4/22 Attachments A,C-K have all been signed prior to contract signing and are saved in ADFP's files. <br />