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Consolidated Agreement FYI Page 27 of 33 STATE CERTIFICATIONS Contractor Certifications Required by North Carolina Law Instructions: The person who signs this document should read the text of the statutes and Executive Order listed below and consult with counsel and other knowledgeable persons before signing. The text of each North Carolina General Statutes and of the Executive Order can be found online at: • Article 2 of Chapter 64: httpJ/www.ncga.state.nc.us/FnactedLegislation/Statutes/PDFByArticle/Chapter 64/Article 2.pdf • G.S. 133-32: http://www.ncg&stme.nc.us/gascriptdstatuteststaMWI00kup.pl?stmtc=133-32 • Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009): http://www.othicscommission.nc.gov/library/pdfAAws/EO24.pdf • G.S. 105-164.8(b): http://www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter 105/GS_105-164.8.pdf • G.S. 143-48.5: httpJ/www.ncga.state.nc.us/EnactedLegislation/Statutcs/HT U-/BySection/Chapter 143/GS_143-48.5.htmi • G.S. 143-59.1: httpJ/www.ncga.state.nc.us/EnactedLegisMon/Statutes/PDFA3ySecfon/Chapter 143/GS_143-59.1.pdf • G.S. 143-59.2: httpJ/www.ncga.state.nc.us/EnactedLcgislation/Statut=MDFBySection/Chapter l43/GS_143-59.2.pdf • G.S. 143-133.3: httpJ/www.ncga.state.nc.us/EnactedLegislation/Statute&4frMLJBySection/Chapter 143/GS_143-133.3.html • G.S. 1438-139.6C: httpJ/www.ncga.state.nc.us/EnactedLegislation/Statutes/PDFBySection/Chapter 143B/GS_143B-139.6C.pdf Certifications (1) Pursuant to G.S. 133-32 and Executive Order No. 24 (Perdue, Gov., Oct. 1, 2009), the undersigned hereby certifies that the Contractor named below is in compliance with, and has not violated, the provisions of either said statute or Executive Order. (2) Pursuant to G.S. 143-48.5 and G.S. 143-1333, the undersigned hereby certifies that the Contractor named below, and the Contractor's subcontractors, complies with the requirements of Article 2 of Chapter 64 of the NC General Statutes, including the requirement for each employer with more than 25 employees in North Carolina to verify the work authorization of its employees through the federal E -Verify system." E - Verify System Link: www.uscis.gov (3) Pursuant to G.S. 143-59.1(b), the undersigned hereby certifies that the Contractor named below is not an "ineligible Contractor" as set forth in G.S. 143-59.1(a) because: (a) Neither the Contractor nor any of its affiliates has refused to collect the use tax levied under Article 5 of Chapter 105 of the General Statutes on its sales delivered to North Carolina when the sales met one or more of the conditions of G.S. 105-164.8(b); and (b) [check one of the following boxes] 6eNeither the Contractor nor any of its affiliates has incorporated or reincorporated in a "tax haven country" as set forth in G.S. 143- 59.1(cx2) after December 31, 2001; or ❑ The Contractor or one of its affiliates has incorporated or reincorporated in a "tax haven (4) (5) (6) country" as set forth in G.S. 143-59.1(cx2) after December 31, 2001 but the United States is not the principal market for the public trading of the stock of the corporation incorporated in the tax haven country. Pursuant to G.S. 143-59.2(b), the undersigned hereby certifies that none of the Contractor's officers, directors, or owners (if the Contractor is an unincorporated business entity) has been convicted of any violation of Chapter 78A of the General Statutes or the Securities Act of 1933 or the Securities Exchange Act of 1934 within 10 years immediately prior to the date of the bid solicitation. Pursuant to G.S. 143B -139.6C, the undersigned hereby certifies that the Contractor will not use a former employee, as defined by G.S. 143B-139.6C(d)(2), of the North Carolina Department of Health and Human Services in the administration of a contract with the Department in violation of G.S.143B-139.6C and that a violation of that statute shall void the Agreement. The undersigned hereby certifies further that: (a) He or she is a duly authorized representative of the Contractor named below; (b) He or she is authorized to make, and does hereby make, the foregoing certifications on behalf of the Contractor; and (c) He or she understands that any person who knowingly submits a false certification in response to the requirements of G.S. 143-59. land -59.2 shall be guilty of a Class I felony. Contractor's Name: Lee County Health Department Contractor's / Authorized Agent: Sienadme �✓ Date Printed Name Title Awl* .ii � iGcti/ Witness: Signature Date Printed Name Title Ile witness should be present when the Contractor's Authorized Agent signs this certification and should sign and date this document immediately thereafter.