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d i,6 uryR 1 0 9 rA COMMUNITY ACTION AGENCY, INC. 1300 W. Bank St. • Salisbury, NC 28144 • Phone: (704) 633 -6633 • Fax: (704) 633 -7814 William "Pete" Kennedy, Board Chairman � \SB gy - Tammy Corpening, Treasurer Donna W. Cook, Vice Chair y P. 9, Carlos Watson, Parliamentarian Suzette Davis, Secretary V�Cf� �" Stanley Wilson, Executive Director Cl;enging People's Lives G� State Grant Certification — No Overdue Tax Debts 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 -1b. Sworn Statement: [William 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. Board Chair Executive Director 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. nc.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." Page 1 of 1 MS &NCD Form 0008 Eff. July 1, 2005 Revised July 18, 2006, 7/07, 8/09, 9/11 An Equal Opportunity Employer www.srcaa.com Attachment number 3 F -6 Page 97