HomeMy WebLinkAboutS NC State firemen's and Rescue Squad Annual Certification Roster 03-16-2010-4f North Carolina State Firemen's Association
323 West Jones Street, Suite 401
Raleigh,NC 27603
1-800-253-4733
2009
ANNUAL CERTIFICATION OF FIREMEN
North Carolina General Statute 58-86-25 requires that all certified fire departments submit a complete roster of
its eligible firemen annually. This certified list determines eligibility for the$50,000 line-of-duty death
benefit as well as eligibility for Pension Fund credit. Failure to accurately and promptly report this
information is violation of G.S. 58-86-25 and will automatically result in a loss or reduction of benefits.
REPORT BY FIRE DEPARTMENT CHIEF
As Fire Department Chief, I have determined that the attached roster is a valid and accurate list of all eligible
firemen,within the definition contained in North Carolina General Statute 58-86-25.
Name of Fire Department d('Cl./1c,4?_ SQ,'�,'�-V Gtdln ,m ,nf-
Fire Department Mailing Address /b �(e vJc,�4.;1Ck,14S it C't UV__
City }��( �S(p��i'C�-G�n State /��. Zip Code o o� 7 c0
Name of Fire Chief �q,U,� �Vlke_s
(Please print or type)
Signature of Fire Chief
Date o2' 3 '- 07 d(0 Daytime Telephone 0160
County Q C���c��
CERTIFICATION BY GOVERNING BODY
Pursuant to G.S. 58-86-25,the governing body of a fire department operated by(i)a county is the county board
of commissioners, (ii)a city is the city council, (iii)a sanitary district is the sanitary district board, (iv)a
corporation, whether profit or nonprofit, is the corporation's board of directors and(v)any other entity is that
group designated by the board. Therefore, in our capacity as the governing body of the above-named fire
department,we certify and find that the attached roster is a valid and accurate list of all eligible firemen in
accordance with G.S. 58-86-25.
Name of Governing Body
Name of Governing Body Offic' 1
(PI se print or type)
Authorized Signature Title �JI�i-Q,�t.L c (3 ��C
Date `� � �� Daytime Telephone_( 2, W�- 2