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DocuSign Envelope ID: 4909266A- 4CCB- 4CD9- BDDF- F47C66COC89C <br />CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY <br />State of N o i—k (= bAGL _ <br />County Q . <br />1, - oom's Mww(L L 0 J Notary Public for said County and State, certify that <br />.rck G I u e. 1,A er 3e it5 personally appeared before me this day and acknowledged <br />that he /she is �,' rv' 6-;b r of 1" J-, f i )i So _ i c '�e rvl (iy <br />[name of Organization] <br />and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of <br />Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held <br />on the /(2 - -- -- day of VC-0 er , ADO , <br />Sworn to and subscribed before me this to „ day of b C-CD 6-e,r 1 dot 7 <br />TOMAS MATkRIN <br />Notary Public <br />Wake Co., North Carolina <br />(Official Seal) 0( �1 rEa:N My Commission Expires iXE-2M <br />My Commission expires _ u {, 7 20 7-z- <br />■r1tY ■eRlltla rMr1111M ■ ■f tl6elRtllleeretlaefr 'erietrll ■ ■eYir tltlrre ■1[r ■ ■FAre ■ ■Ila ■i ■asetlrrrse■ <br />Instruction for Organization: <br />Sign and attach the following pages after adopted by the Board of DirectorsMustees or other <br />governing body OR replace the following with the currant adopted conflict of Interest policy. <br />Name of Organization <br />V� L-^°'°'°' <br />Signature of organization Official <br />NCDHHS CO11 0 13 (Rev. 4/11) <br />u <br />