2016-673-E Finance - Inter-Faith Council for Social Service - Outside Agency Performance Agreement

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DocuSign Envelope ID:82431AC9-7F03-4084-815E-A2EFB34C92BB t A - continued . . ProvidersradAitAyrkffilication I.) 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 X Ej a) Employees of or closely related to employees of the Town of Chapel Hill, Orange County, Carrboro, or Hillsborough? EI X b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, Hillsborough, or Orange County? X El c) Current beneficiaries of the project/program for which funds are requested? X Ej 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 of our Board Members is a part-time Town of Carrboro Parks & Recreation Dept. employee, with a sister who works part-time for the Town of Carrboro and a daughter who works for the Chapel Hill Carrboro City Schools. • We have another Board Member whose husband works for the Town of Carrboro. • One of our Board Members has a daughter who receives services from Vocational Rehabilitation. • Two of our Board Members work for Piedmont Health Services, one of our partner agencies located within our residential facility. 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 the termination of any grant awarded. ) Th ( _, .2 2 -;,?, 0(/ Signaturgi : ,),`,.471,1 'lb I:ExeCutivef Director Date . . . , Sign ature: :oard Chairperson Date Main Application 1/25/2016 12:58:53 PM Page 19 of 3 3