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Signature: <br />The undersigned Energy Provider hereby agrees and warrants to the State of North Carolina and the <br />County Department, that the undersigned will comply with the terms and conditions outlined in this <br />Agreement to receive monies under the Low-income Home Energy Assistance Program. <br />hereby declare that i have read and understand the above and agree to comply and abide with the <br />terms and conditions specified while participating in the program. <br />Dominion Energy <br />(Print Company Name) <br />(Signature of CApany Representative) <br />- \'Q <br />(Date) <br />ilk Q ikA- <br />(Print Mailing Address) <br />(Print City, State, Zip Code) <br />(Telephone Number) <br />(Provider Federal ID Number (FEIN) or SSN) <br />9.,e: .k -`('CZ-r, „o <br />(Primary E-mail Address) <br />P. <br />(Primo e Di tor4Name) , <br />(Siinature of Count Director) <br />S-` ,\ <br />(Date) <br />PO Box 1066 <br />(Print Mailing Address) <br />Sanford NC 27331 <br />(Print City, State, Zip Code) <br />(Telephone Number) <br />(Primary E-mail Address) <br />DSS -8163 (06/18) Page 3 of 3 <br />Economic and Family Services <br />