2016-574 Finance - Orange County Living Wage - Outside Agency Performance Agreement

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EXHIBIT A - continued Provider's Outside Agency Application MAIN APPLICATION 1.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST Are any of the Board Members or employees of the agency which will be carrying out this project, or members of their immediate families, or their business associates: YES NO **❑ a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? See comment below. c) Current beneficiaries of the project/program for which funds are requested? d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below, One board member who is on the certification team currently serves on the Orange County Housing Authority and is running for a seat on the Orange County Commissioners. These roles would not appear to present a conflict of interest in regard to the work of Orange County Living Wage or our application for this grant. If elected,he would not take office before decisions about the grant are made. if decisions about funding our organization were made in later years and he is on the board of commissioners, he would need to decide whether to recuse himself. To the best of my knowledge and belief all of the above information is true and current I acknowledge and understand that the existence of a potential conflict of interest does not necessarily make the project ineligible for funding, but the existence of an undisclosed conflict may result In the termination of any grant awarded. ;Z Signature: Chair of Bp of Direc Steering Committee Date Signature: IX 1-116 Vice Chair of Board of Directors Date 7 AAr;n 11-Zn-07 AKA