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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 /> Dominion Energy N \ ` 'G v t <br /> (Print Company Name) Print County Director Name) <br /> (Signature of Corapany Representative) (Signature of County Director) <br /> LA—CeS`3Q��� , S/I$/ ?O O <br /> (Date) (Date) <br /> (Print Mailing Address) (Print Mailing Address) <br /> t C30 A4r- Se9 >c{+-, ,--rk KA_ Z-)33I <br /> (Prinf City,State,Zip Code) (Print City,State,Zip Code) <br /> 10Lk— sc GL`i-716 -LtyC-(o <br /> (Telephone Number) <br /> Number) (Telephone Number) <br /> 5!.?r` ►PN% `�z ra voe c l I r c Civ.-N�. ►-�c . c n <br /> (Provider Federal ID Number(FEIN)or SSN) (Primary E-mail Address) <br /> (Primary E-mail-Address) <br /> Cha;S, Lee Coun4y)toZ Con cn\ss►one( <br /> pin4AigiDatiArre›2--- <br /> DSS-8163 (06/18) Page 3 of 3 <br /> Economic and Family Services <br />