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DocuSign Envelope ID:87560079-2786-4376-A189-DC48D9482BE7 <br /> NC DEPARTmlENr. OF PUBLIC SAFETY •. NOT FOR PROFIT <br /> DPS CONFLICT OF INTEREST POLICY STATEMENT <br /> 1. 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 Bry (Date of Signature) <br /> Name: Sign I12412-Di 7 <br /> Board Chair's Print Jennifer L. Mardi. _ (Date of Signature) <br /> • Name: Sign f ! I /_�" ce-- /7 <br /> 70- <br /> Sworn to and subscribed before me on the Jaime E Ledbetter <br /> Day of the date of said irtifitition NOTARY PUBLIC <br /> Forsyth County, NC <br /> 8°I/L4-(1`fotarYPu‘bl ic1 ; <br /> E /re° /OJ/Er/2 <br /> is <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 />