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it ?ASE 521 STATE OF NORTH CAROLINA 1 DEPARTMENT OF STATE AUDITOR FIREMEN'S AND RESCUE SQUAD WORKER'S PENSION FUND DIVISION • 300 N. SALISBURY STREET RALEIGH, N. C. 17611 ANNUAL CERTIFICATION OF FIREMEN General Statutes, Chapter 118-23, requires that all certified fire departments certify annually to the N. C. Firemen's Pension Fund a complete roster of its qualified firemen. The following certification along with a complete roster of all active firemen* as of June 30 of each year must be submitted to the N. C. Firemen's Pension Fund, 116 W. Jones I St., Raleigh, N. C. on or before July 31. Failure to submit this certification along with a complete roster will result in the loss of the death benefit provided by the State. CERTIFICATION • We, the in our capacity as the governing Governing Body body of the Fire Department, certify that we have examined and find that attached is a true and accurate list of all active firemen* of the Fire Department, address County of North Carolina. Signed Title Date For Fire Department Chief Only Chief of the ___~,f eS'[ J1~v,~ Fire Department, certify the attached roster is a true and accurate list of all eligible fire- men. (Eligible firemen are firemen who have met the required 36 hours of meetings and drills during the last calendar year (July 1 - June 30). In addition, the term "eligible firemen" shall mean those firemen who have joined the fire department within the calendar year and 'are in the process of completing the required 36 hours of a tings And drills.) Q71~ F' e Chief Date ROSTER MUST BE ATTACHED WITH NAMES IN ALPHABETICAL ORDER. ® *Firemen on authorized "Leave of Absence" are to be included on the roster. Mienever a new fireman is added to the roster during the year, his or her name should be forward to the tension Fund Office inmediately.