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July 1, 2007 <br />To: State Agency Head and Chief Fiscal Officer <br />Certification: <br />We certify that the (agency's name) does not have any overdue tax debts, as <br />defined by N.C.G.S. I OS-243,1, at the federal, State, or local level. We fwther understand that any person who makes a <br />false statement in violation of N.C.G.S. 143-6,2(b2) is guilty of a criminal offense punishable as provided by N.C.G.S. <br />143-34(b). <br />Sworn Statement: <br />(Board Chair) and (Board Treasurer) <br />being duly sworn, say that we are the Board Chair and Board Treasurer, respectively, of <br />(Agency's name) of (City) in the State of <br />North Carolina; and that the foregoing certification is true; accurate and complete to the best of our knowledge and was <br />made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the <br />appropriate authorities for fwther action. <br />Board Chair <br />Board Treasurer <br />Sworn to and subscribed before me on the day of the date of said certification. <br />(Notary Signature and Seal) <br />MyConunission Expires: <br />-f there are any questions, please contact the North Carolina Office of the State Auditor: <br />Angela Gunn @ (919) 807-7556 or <br />Harriet Abraham @ (919) 807-7673. <br />DHHS (Contract) (General) (03/07). ~, a <br />