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Residential Emergency Repair Program <br />Certification of Non-Filing of State Income Tax Return <br />Name:_______________________________ <br />Name:_______________________________ <br />Address:_____________________________ <br /> ______________________________ <br />STATE OF HAWAI'I ) <br /> ) SS: <br />COUNTY OF HAWAI'I ) <br /> The undersigned hereby certify that the borrower (s), pursuant to the laws and regulations as <br />established by the State of Hawai'i Department of Taxation, did not file a State Income Tax Return for the <br />tax year __________, and that the borrower (s) understand that misrepresentation of information or <br />failure to disclose information will constitute just cause for the County to call the loan immediately due <br />and payable. <br />___________________________________ <br />BORROWER <br />___________________________________ <br />BORROWER <br />Subscribed and sworn to before me <br />this_______ day of ________________, 20____. <br />________________________________________ <br />Notary Public, State of Hawai'i <br />My commission expires:_____________________ <br /> <br />