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MAIN APPLICATION <br />I.) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST <br />Are any of the Board Members or employees of the agency which will be carrying out this project, or <br />members of their immediate families, or their business associates: <br />YES NO <br />❑ X a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br />County, Carrboro, or Hillsborough? <br />❑ X b) Members of or closely related to members of the governing bodies of Chapel Hill, <br />Carrboro, Hillsborough, or Orange County? <br />❑ X c) Current beneficiaries of the project/program for which funds are requested? <br />❑ X 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, please provide a full explanation below. <br />To the best of my knowledge and belief all of the above information is true and <br />current. I acknowledge and understand that the existence of a potential conflict of interest <br />does not necessarily make the project ineligible for funding, but the existence of an <br />undisclosed conflict may result in the termination of anv arant awarded. <br />Signature: IV_;cy -1 Jl10 <br />E ?cecutive Director <br />Signature: FJ[l, j �, �1/✓✓�t°t<!� ` �" " `� <br />Boar Chairperson <br />Date <br />Date <br />Main Application 1/25/2016 11:36:35 AM P a g e 1 0 o f 1 6 <br />