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LVA rlul►, - •�r�L•��i <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 />® ❑ a) Employees of or closely related to employees of the Town of Chapel Hill, Orange <br />County, Carrboro, or Hillsborough? <br />❑ ® b) Members of or closely related to members of the governing bodies of Chapel Hill, <br />Carrboro, Hillsborough, or Orange County? <br />❑ �} c) Current beneficiaries of the project/program for which funds are requested? <br />❑ ® d) raid 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 />Board member Elisabeth Johnson's partner Kennard Winchester is a school bus driver for the <br />Chapel Hill Carrboro City Schools and works as a basketball coach for the Phillips Middle School <br />boys team, <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 any grant awarded. <br />Signature: zy <br />Executive Director Date <br />Signature: 1/2,L4 I <br />and Chairperson Date <br />Main Application 1/24/2016 2:59:42 PM Page 42 of 58 <br />