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ATTACHMENT E -OVERDUE TAXES <br />Instructions: Crrantee should complete this certification for all funds received. Entity <br />should enter appropriate data in the yellow highlighted areas. The completed and signed <br />form must be provided to the County Department of Social Services. <br />Ent1ty's. Letterhead <br />July 1, 2007 <br />To: Cabarrus County Department of SociaLServ~es <br />Certification: <br />We certify that Carolinas Medical Center-NorthEasUChild Advocacy Center does not have any <br />overdue tax debts, as defined by N.C.G.S.105.243.1, at the federal, State, or local level. We <br />further understand that any parson who makes a false statement in violation of N.C.G.S. t 43- <br />8.2(b2) [s guilty of a criminal offense punishable as provided by N.C.G,S. 143-34(b), <br />sworn statement:.. <br />[Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we <br />are the Board Chair and [five of the Second Authorizing Officiaq, respectively, of Carolinas <br />Medical CentervNodhEast, Concord in the State of North Carolina; and-that the foregoing <br />certification.isuue, accurate and complete to the best of our knowledge and was made and <br />sutiscdbed by us. We also acknowledge and understand that any misuse of State funds will be <br />reported to the appropriate authorities for further action. <br />[7 Secon Authorizing Official]-vial] <br />Sworn to and subscribed before ma on the day of the date of said certification. <br />My Commission Expires: <br />(Notary Signature and Seal) <br />F-~~ <br />