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IRAN DIVESTMENT ACT CERTIFICATION REQUIRED BY N.C.G.S. <br />143C-6A-5(a) <br />Name of Contractor, Vendor or Bidder: <br />As of the date listed below, the contractor, vendor or bidder listed above, and all subcontractors <br />utilized by the contractor, vendor or bidder listed above, is not listed on the Final Divestment <br />List created by the State Treasurer pursuant to N.C.G.S. 143-6A-4. <br />The undersigned hereby certifies that he or she is authorized by the contractor, vendor or bidder <br />listed above to make the foregoing statement. <br />Signature Date <br />Printed Name Title <br />Notes to persons signing this form: <br />N.C.G.S. 143C-6A-5(a) requires this certification for bids or contracts with the State of North <br />Carolina, a North Carolina local government, or any other political subdivision of the State of <br />North Carolina. The certification is required at the following times: <br />□When a bid is submitted <br />□When a contract is entered into (if the certification was not already made when the vendor <br />made its bid) <br />□When a contract is renewed or assigned <br />N.C.G.S. 143C-6A-5(b) requires that contractors with the State, a North Carolina local <br />government, or any other political subdivision of the State of North Carolina must not utilize <br />any subcontractor found on the State Treasurer’s Final Divestment List. The State Treasurer’s <br />Final Divestment List can be found on the State Treasurer’s website at the address <br />www.nctreasurer.com/Iran and will be updated every 180 days. <br />*****Contractor, Vendor or Bidder – Return This Form with All Other Required Documentation***** <br />Docusign Envelope ID: 5A9E3BC2-EAE1-4C35-82D9-B4D6A375FA78