Orange County NC Website
Browse       Search
North Carolina State Firemen's Association <br /> 323 West Jones Street, Suite 401 <br /> Raleigh,NC 27603 <br /> 1-800-253-4733 <br /> 2009 <br /> ANNUAL CERTIFICATION OF FIREMEN <br /> North Carolina General Statute 58-86-25 requires that all certified fire departments submit a complete roster of <br /> its eligible firemen annually. This certified list determines eligibility for the$50,000 line-of-duty death <br /> benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this <br /> information is violation of G.S. 58-86-25 and will automatically result in a loss or reduction of benefits. <br /> REPORT BY FIRE DEPARTMENT CHIEF <br /> As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible <br /> firemen,within the definition contained in North Carolina General Statute 58-86-25. <br /> Name of Fire Department d('Cl./1c,4?_ SQ,'�,'�-V Gtdln ,m ,nf- <br /> Fire Department Mailing Address /b �(e vJc,�4.;1Ck,14S it C't UV__ <br /> City }��( �S(p��i'C�-G�n State /��. Zip Code o o� 7 c0 <br /> Name of Fire Chief �q,U,� �Vlke_s <br /> (Please print or type) <br /> Signature of Fire Chief <br /> Date o2' 3 '- 07 d(0 Daytime Telephone 0160 <br /> County Q C���c�� <br /> CERTIFICATION BY GOVERNING BODY <br /> Pursuant to G.S. 58-86-25,the governing body of a fire department operated by(i)a county is the county board <br /> of commissioners, (ii)a city is the city council, (iii)a sanitary district is the sanitary district board, (iv)a <br /> corporation, whether profit or nonprofit, is the corporation's board of directors and(v)any other entity is that <br /> group designated by the board. Therefore, in our capacity as the governing body of the above-named fire <br /> department,we certify and find that the attached roster is a valid and accurate list of all eligible firemen in <br /> accordance with G.S. 58-86-25. <br /> Name of Governing Body <br /> Name of Governing Body Offic' 1 <br /> (PI se print or type) <br /> Authorized Signature Title �JI�i-Q,�t.L c (3 ��C <br /> Date `� � �� Daytime Telephone_( 2, W�- 2 <br />