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onnunign Envelope ID:r2cnooEs+DFsA-471E-so71-CCon000nnne1 <br /> EXHIBIT <br /> PROVIDERS OUTSIDE AGENCY APPLICATION <br /> d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION <br /> CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this program <br /> or members of their immediate families, or their business associates... <br /> YES NO <br /> }( 0 a) Employees of or closely related to employees of the Town of Carrboro, the Town of <br /> Chapel Hill, or Orange County? <br /> [� <br /> �� C b) Members of or closely related to members of the governing bodies of the Town of <br /> Carrboro, the Town of Chapel Hill, or Orange County? <br /> [� <br /> . . - c) Current beneficiaries of the program for which funds are being requested? <br /> E�_ d\ 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, <br /> Jabe Hunter is a member of the Chapel Hill Police Department, but he does not receive any <br /> benefit from these grant funds. His job as a police officer does not pose a conflict of <br /> interest with El providing affordable rental housing. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the <br /> parties hereto for themGe|vao, their agents, officials, employees and servants agree not to <br /> discriminate in any manner of these basis of race, gender, national origin, ago, h@ndic8p, <br /> r8}igion, sexual oriHntoUon, gender identitv/expneoai0n, familial status or veteran status with <br /> reference to any activities carried out by the gnantee, no matter how remote. The parties <br /> hereto further agree in all respects to conform to the provision and intent of Orange County <br /> Civil Rights Ordinance as arnended, and the Orange County Anti-discrimination Policy. This <br /> provision is enforced by action for specific perfornnonoe, injunctive relief, or other remedy as <br /> by law provided; this provision shall be binding on the grantees, the successors and assigns <br /> of the parties hereto with reference to the above subject manner. <br /> To the best of my knowledge and belief all of the above information is true and <br /> curment' I acknowledge and understand that the existence of a potential conflict of interest <br /> does not necessarily make the program ineligible for funding, but the existence of an <br /> undisclosed conflict may result in the termination of any qrant awarded. <br /> k ~~�� /' �J �- / �7 <br /> Signature { / '~ ~` -~ - / 7^ <br /> c xGout|ve Director Date <br /> Signature: - ( t) ( / <br /> -7 <br /> Unoc Chairperson Date <br /> AGENCY INFORMATION 1/25/2017 9:41:22 AM r' a g e. 7 0f 7 :,:, <br />