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DocuSign Envelope ID:AB039DC1-8309-4D41-B525-6E84F973FAA6 <br /> 4.7.,.. .4N. <br /> mr---40P-3 <br /> NC DEPARTMENT OF PUBLIC SAFETY <br /> DpS <br /> NOT FOR PROFIT <br /> "1......' V DPS CONFLICT OF INTEREST POLICY STATEMENT <br /> I. If "yes" is checked to any of the aforementioned items, the JCPC Program <br /> Manager and Board Chair must ensure details for any transaction that exists are <br /> described and attached to this form. <br /> 2. If this statement fails to list a transaction that may exist that is non-financial in <br /> nature, please attach details. <br /> 3. Details must include at least the name, and, address, or persons involved, and a <br /> description of the relationship and the transaction. <br /> Note: Failure to disclose any conflict of interest transaction that exists or is <br /> potential within your private,nonprofit entity may result in the cessation <br /> of any further DPS JCPC State funds. <br /> County: Alamance <br /> Agency's Name: <br /> (Legal Applicant) Exchange Club Center for the Prevention of Child Abuse of North <br /> Carolina, Inc. <br /> Federal Tax ID#: <br /> Private,Nonprofit <br /> Entity Name: The Exchange Club's Family Center in Alamance <br /> Executive Director's Print George Brya• (Date of Signature) <br /> Name: Sign 1/2.4124/ 7 <br /> Board Chair's Print Jenni - L. Marti (Date of Signature) <br /> -- <br /> Name: Sign ioffiralre j /-e ce-- /7 <br /> 7....."0111■ <br /> 41 le <br /> Jaime E Ledbetter <br /> Sworn to and subscribed before rue on the NOTARY PUBLIC <br /> Day o the date of saidezertifi i I tion <br /> - —fill■ Forsyth County, NC <br /> , 4 iv _ - ,, <br /> div, A <br /> 7 - (Notary Public <br /> EX—pit Co .' /01/8/2 .) <br /> Form DPS 13 001 Not for Profit DPS Conflict of Interest Policy Statement <br /> Form structure last revised July 2014 <br /> NC Department of Public Safety Page 3 of 3 <br />