Fillable CERTIFICATION FOR DISTRICT SUPERVISORS I, , Supervisor, of (Information Technology Services)

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CERTIFICATION FOR DISTRICT SUPERVISORS I, , Supervisor, of (Information Technology Services)

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Version 4.4.12 DSWC Form 201
http://www.ncagr.gov/swc/districts/forms.html
DIVISION OF SOIL AND WATER CONSERVATION
North Carolina Department of Agriculture & Consumer Services
1614 Mail Service Center • Raleigh, NC 27699-1614
919.733.2302 • www.ncagr.gov/swc/
CERTIFICATION FOR DISTRICT SUPERVISORS
Complete and submit online through SharePoint; keep original for district file
I, , Supervisor, of Soil and Water Conservation District,
do hereby certify that:
I AM
NOT a “state employee”, and I DO NOT receive a salary from funds
deposited with the State Treasurer.
I AM a “state employee”, and I DO receive a salary from funds deposited with
the State Treasurer.
X
Su
pervisor’s printed name Supervisor’s signature
Dat
e
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CERTIFICATION FOR DISTRICT SUPERVISORS I, , Supervisor, of (Information Technology Services)

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Completed 14 August 2020

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