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State Grant Certification — No Overdue Tax Debts Instructions: Grantee/Provider 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 the O ffice of State Budget and Management. Note: fj'you have a contract that extends more than one state fiscal year, you will need to obtain an updated certification,for each year ofthe contract. Entity's Letterhead [Date of Certification (mmddyyyy )] To: State Agency Head and Chief Fiscal Officer Certification: We certify that the [Salisbury Rowan Community Action Agency] does not have any overdue tax debts, as defined by N.C.G.S. 105 - 243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C- 6 -23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143C -10 -1 b. Sworn Statement: [William "Pete" Kennedy] and [Stan Wilson] being duly sworn, say that we are the Board Chair and [Executive Director], respectively, of [Salisbury Rowan Community Action Agency] of [Salisbury] in the State of [North Carolina]; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. William Kennedy [Board President] Sworn to and subscribed before me on the day of the date of said certification. (Notary Signature and Seal) My Commission Expires: If there are any questions, please contact the state agency that provided your grant. If needed, you may contact the North Carolina Office of State Budget and Management: NCGrants @osbm. ne.gov- (919)807 -4795 ' G.S. 105 -243.1 defines: Overdue tax debt. — Any 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 include a tax debt, however, if the taxpayer entered into an installment agreement for the tax debt under G.S. 105 -237 within 90 days after the notice of final assessment was mailed and has not failed to make any payments due under the installment agreement." MS &NCD Form 0008 Page 40 of 49 Eff. July 1, 2005 Attachment number 2 G -2 Page 317