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DocuSign Envelope ID: 23D00540- 4B67- 4A91- B622- 510CAEF24EEE <br />,� <br />N4.l mCtROL111NADEPARTi1fENT 0FJUVEAUE <br />JI1sT2'CR lND D.E.FINQ UENCT PREPENTioAr <br />CONFLICT D.F L1 TEREST POLICY STATEMENT <br />The following serve-s to idendlfy and document any personal interest staff members, <br />officers, and members of the Board of Directors may have. This document is also to be <br />used to disclose any transacfionsr that may result In personal, frmaacr'44 professional.' <br />andfor political gain at the expense of the NC Depanment of 1uwnHe Justice and <br />DelinquenU Prevention. The statement requires that aft personal relationships that <br />may inappropriately influence (bias) ra=tions be Disclosed. Reladonshrps, be it <br />personrclr , financ* professional andlor political are required to be 4veloserd to tills <br />Department; Conflict means a conflict or the appearance of a conflict between the <br />private interests and official responsibilities of aperson in a pdsidon of trust. Persons <br />in a position of trust include! staff memhem or the Board of Director L <br />Private, nonprofit entities shall make M disdosun by notice in writing to the frill <br />Governing Board/Comcit all conflicts of interest, if "yes" is answered to any of the <br />following: (Check all that apply) <br />FormDtJDP 13 001 Conflict of Interest PoliryForm <br />Form straature last revised 04/2011 <br />Alorih C4roliz s Deparhnent of Juvenile JUWC -- and Vclinqumay Prevention Page 2 of 3 <br />YES <br />NO <br />1. A Board member is related to a staff member. <br />x <br />2. A staff ju bw in a supervisory capacity is related to another staff <br />X <br />member wham helsbe s ervises.. <br />3. A staf'finembcr is related to another staf£zr!ember. <br />x <br />4. A bovid member or staff member has or may have prrrscirnai, <br />financial, professional, andlor political gain at the expense or <br />x <br />benefit of1he private, no fit entity. <br />5. There is a business entity in which a star, board, or firmly member <br />pmticrpates that may be viewed as having direct or indirect <br />X <br />influence over the private, nonprofit anti 's biisirless, <br />6. A std board, or faintly inember may be viewed as having direct <br />or indirect financial gain from personal or business <br />x <br />investmeatslinterest in real property -held by that staff, board, or <br />family member. <br />7. A staff orboard member received honorarimn or other <br />compensation outside of the scope of employment/operations with <br />x <br />the rivate, norrpzofit enti that creates or ears to create Bias. <br />$. A staff or board member secured employment with a competitor or <br />other similar private, non root anti . <br />x <br />9. Ongoing, paid consulting work outside of the staff member's <br />current employment or board member's with your private, <br />x <br />norit3i'4ftt entity exists. <br />FormDtJDP 13 001 Conflict of Interest PoliryForm <br />Form straature last revised 04/2011 <br />Alorih C4roliz s Deparhnent of Juvenile JUWC -- and Vclinqumay Prevention Page 2 of 3 <br />