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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 County, <br />Carrboro, or Hillsborough? <br />❑ x b) Members of or closely related to members of the governing bodies of Chapel Hill, Carrboro, <br />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 the <br />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 current. <br />I acknowledge and understand that the existence of a potential conflict of interest does not <br />necessarily make the project ineligible for funding, but the existence of an undisclosed <br />conflict may result in the termination of any grant awarded. <br />Signature: <br />Signature: <br />Exe ive! Di r cto F1- ear <br />Board Chairperson <br />/Jd I <br />Date <br />t 125 zo <br />Date <br />Main Application 1/21/2016 12:57:09 PM F a g (- 12 o f 1 <br />