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26 <br /> State Grant Certification — No Overdue Tax Debts <br /> Instructions: Grantee/Contractor should complete this certification for all state funds received. Entity should <br /> enter appropriate data in the yellow highlighted areas. The completed and signed form should be <br /> provided to the state agency funding the grant to be attached to the contract for the grant funds. A <br /> copy of this form, along with the completed contract, should be kept by the funding agency and <br /> available for review by the Office of State Budget and Management. <br /> Note: If you have a contract that extends more than one state fiscal year,you will need to obtain an updated certification for <br /> each year of the contract. <br /> Entity's Letterhead <br /> [Date of Certification (mmddyyyy)] <br /> To: Nancy Coston, Director, Orange County Department of Social Services <br /> Certification: <br /> We certify that the [insert organization's name] does not have any overdue tax debts, as defined <br /> by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person <br /> who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense <br /> punishable as provided by N.C.G.S.) 143C-10-1b. <br /> Sworn Statement: <br /> [Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we are <br /> the Board Chair and [Title of the Second Authorizing Official], respectively, of[insert name of <br /> organization] of[City] in the State of[Name of State]; and that the foregoing certification is true, <br /> accurate and complete to the best of our knowledge and was made and subscribed by us. We also <br /> acknowledge and understand that any misuse of State funds will be reported to the appropriate <br /> authorities for further action. <br /> Board Chair <br /> [Title of Second Authorizing Official] <br /> Sworn to and subscribed before me on the day of the date of said certification. <br /> My Commission Expires: <br /> (Notary Signature and Seal) <br /> If there are any questions, please contact the state agency that provided your grant. If needed,you may contact the North <br /> Carolina Office of State Budget and Management: <br /> NCGrants@osbm.nc.gov-(919)807-4795 <br /> ' G.S. 105-243.1 defines: Overdue tax debt.—Any part of a tax debt that remains unpaid 90 days or more after <br /> the notice of final assessment was mailed to the taxpayer. The term does not include a tax debt, however, if the <br /> taxpayer entered into an installment agreement for the tax debt under G.S. 105-237 within 90 days after the <br /> notice of final assessment was mailed and has not failed to make any payments due under the installment <br /> agreement." <br /> Page 1 of 1 <br /> MS&NCD Form 0008 <br /> Eff.July 1,2005 <br /> Revised July 18,2006,7/07,8/09,9/11 <br />