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26 <br /> B. Non-profit agencies only:Verification of 501(c)(3)Status Form <br /> IRS Tax Exemption Verification Form (Annual) <br /> I, , hereby state that I am of <br /> (Printed Name) (Title) <br /> ("Organization"), and by that authority duly <br /> (Legal Name of Organization) <br /> given and as the act and deed of the Organization, state that the Organization's status continues <br /> to be designated as 501(c)(3) pursuant to U.S. Internal Revenue Code, and the documentation on <br /> file with the North Carolina Department of Health and Human Services is current and accurate. <br /> I understand that the penalty for perjury is a Class F Felony in North Carolina pursuant to N.C. <br /> Gen. Stat. § 14-209, and that other state laws, including N.C. Gen. Stat. § 143C-10-1, and federal <br /> laws may also apply for making perjured and/or false statements or misrepresentations. <br /> I declare under penalty of perjury that the foregoing is true and correct. Executed on this the <br /> day of , 20 <br /> (Signature) <br /> 2 <br />