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DocuSign Envelope ID:40C90B7F-D85F-4E1C-A5CA-4BC263526A8E t A - continued <br /> Provider's aNAAgEafaiigication <br /> I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br /> Are any of the Board Members or employees of the agency which will be carrying out this project, or <br /> members of their immediate families, or their business associates: <br /> YES NO <br /> Ti 7,17a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br /> County, Carrboro, or Hillsborough? <br /> 111 iI b) Members of or closely related to members of the governing bodies of Chapel Hill, <br /> Carrboro, Hillsborough, or Orange County? <br /> E1/c) Current beneficiaries of the project/program for which funds are requested? <br /> El Paid providers of goods or services to the program or having other financial interest in <br /> the program? <br /> If you have answered YES to any question, please provide a full explanation below. <br /> To the best of my knowledge and belief all of the above information is true and <br /> current. I acknowledge and understand that the existence of a potential conflict of interest <br /> does not necessarily make the project ineligible for funding, but the existence of an <br /> undisclosed conflict may result in the termination of any grant awarded. <br /> Signature:(p, ) ()),&,_ j-/.__e:((2 / <br /> Executive Director Date <br /> Signature: (11a2" <br /> Board Chairperso D <br /> Main 4nnliratinn 1/7117n1R Q.R"4..cF 4AA P a' 9 9 <br />