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ATTACHMENT E - OVERDUE TAXES <br />Instructions: Grantee should complete this certification for all <br />funds received. Entity should enter appropriate data in the yellow <br />highlighted areas. The completed and signed form must be provided <br />to the County Department of Social Services. <br />DBte of Certificatlon 05114/2007 <br />To: Cabarrus County Department of Social Services <br />Certification: <br />We certify that Good Health Services, Inc. does not have any overd~e tax <br />debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local <br />level. We further understand that any person who makes a false statement <br />in violation of N.C.G.S. 143-62(b2) is guilty of a criminal offense <br />punishable as provided by N.C.G.S. 143-34(b). <br />Sworn Statement: <br />Tony McCurdy, Board Chair and Lisa McCurdy, Second Authorizing Official <br />being duly sworn, say that we are the Board Chair and Vice President, <br />respectively, of Good Health Services, Inc. of Raleigh in the State of North <br />Carolina; and that the foregoing certification is true, accurate and complete <br />to'the best of our knowledge and was made and subscribed by us. We <br />also acknowledge and understand that any misuse of State funds will be <br />reported to the approprfate authorities for further action. <br />~d ~., ~. <br />Bo~cf C ai C ~ <br />-~~--,~1'I. fl1 ~ ~ / <br />~ , Vice President ~ <br />Sworn to and subscribed before me on the day of the date of said <br />certification. ~~y~y ,2b07 <br />.-:.._. ...._. ~ <br />/ <br />.~ ..r/.-. ~ ~~(vlyCommission <br />Expir`es: /19/,ty ~2C~O8~ ~ .D [.CkU- <br />(Notary Signature and Seal) <br />~ ` ~C~U~s <br />~pTAq~ <br />•.. <br />'°~e~~~ ~. <br />, ~ ~• . <br />~r-3 <br />