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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 />I 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 />Central Electric Membership Corporation <br />!Print Company Name) <br />(S ture of Company Representative) <br />lA (/ gDate) <br />((Print Mailing Address) <br />4 <br />,(Print <br />(Print City, State Zip Code) <br />PC) 33 <br />ii (\ (Telephone Number) <br />(Provider Federal ID Number (FEIN) or SSN) <br />bLfl' <br />(Primary E-mail Address) <br />\\f‘ \ \ 'A. <br />(riv • <br />P <br />ctor'Nam <br />i nature of Counbt Director) <br />?.1-71V, <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 />