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Aug 18 2023 01 :15PM HP Fax page 2 <br />State Grant.Certification -No Overdue Tax Debts. <br />Instructions: Grantee/Contractor should complete this certification for all state funds received. Entity should enter appropriate data In the yellow highlighted areas. The completed and signed form should be provided to the state agency funding the grant to be attached to the contract for the grant funds, A copy of this form, along with the completed contract, should be kept by the funding agency and available for review by ltle Office of State Budget and Management. <br />NMe: /(you have a co111ract tluit extends more than one s/a/e.fiscal yem; you 11-i// need to obtain an updated cert/.fic(l/ionfor i:uc/1 year of/he co11/l'acl. <br />Holi.stic Tran$portation Service <br />[Date of Certification 08-10-2023] <br />To: State Agency Head and Chief Fiscal Officer <br />Certification: <br />We certify that Holistic Transportation Service does not have any overdue tax debts, as defined by <br />N.C.G.S. 105-243. 1, at the federal, State, or local level. We further understand that any person who <br />makes a false statement in violatlon of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable <br />as provided by N.C.G.S.) 143C-10-1b. <br />Swom Statement: <br />[Annett� McDoWI] and [Ernes{Gr,ayl] being duly sworn, say that we are the Board Chair and <br />[supervl$6r], respectively, of [Holistlc Transportation.S�rvlce] of [Btirilngton] In the State of [North Cardlina]; and that the foregoing certification is true, accurate and complete to the best of our <br />knowledge and was made and subscribed by us. We also acknowledge and understand that any <br />misuse of State funds will be reported to the appropriate authorities for further action. <br />�M(}Mr: Board Chair <br />[�uperviSOJ"],,,um,,,,, .. · ..'-'.._ K �"'1. ·-, <br />Sworn to and subscribed before me on � .Dftl+$ lt>�oli�id certification. . }/ /' , ·1 ,-·�"'Alt,.. .. r·,. �. n. �,(A : I Mt,xinmlsslon Expires: .:Tanuan.4-, J.. !>, ZOt.'1 <br />(1arySignature andSe�) \�\ '°LJ B\..\c, /�l.:U' <br />��· .. �·�·-1'�'!�-...... '�$ If there are any questions, please contact the state a��t �ur grant If needed, you may contact the North Carolina omce of Stale Budget and Management: ''•ten••'' , NCGrants@osbm.nc.gov-(919)807-4795 <br />1 G.S. 105-243.1 defines; Overdue tax debt. -Arr; part of a tax debt that remains unpaid 90 days or more after the notice of final assessment was mailed to the taxpayer. The term does not lndude a tax debt, however, if the taxpayer entered Into an installment agreement for the lax debt under G.S. 105-237 within 90 days after 1he notice of final assessment was malled and has not failed to make any payments due under the installment agreement.• <br />MS&NCD Form 0008l:cff, July 1, 2005 <br />Revised July 18, 2006, 7/07, 6/09, 9111 <br />Page 1 of 1 <br />Attachment E <br />DocuSign Envelope ID: 74375224-B7BF-4B07-89E3-8426200297F5