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Insreuclions: Grantee should complete this certification fir all state funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form should be provi<ed to the state agcne}` funding the grant to be attached to the contract for the grant funds. A copy of this form, along with the completed cmrtract, should be kept by the funding agency and mailable for review by the Office of the State Auditor. If yoo have questions, contact: Angela Gum:, Office of fhc State Auditm•, 919-807- 7556. ATTACHMENT E CERTIFICATION OF NO OVERDUE TAX DEBTS Entity's Letterhead [Date of Certification (mmddyyyy)] To: State Agency Heacl and Chief Fiscal Officer Certification: We certify that the [rnserl orgunizntion's name) 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 uoderstand that any person who makes a 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. 143-34(b). Sworn Statement: [Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we are the Board Chair and [Title of the Second Authorizing Offtcial], respectively, of [insert name of organization] of [City] in the State of [Name of State]; 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. Board Chair [Title of Second Authorizing Official] Sworn to and subscribed before me on the day of the date of said certification. (Notary Signature and Seal) My Camnission Expires: If there are any questions, please contact the North Carolina Office of the State Auditor: Angela Gunn @ (919) 807-7556 or Harriet Abraham @ (919) 807-7673. DHHS (Contract) (General) (03!07) ~ ~ I 12