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DocuSign Envelope ID: 23D00540- 4B67- 4A91- B622- 510CAEF24EEE <br />ra3Wiv 4 i... <br />.i <br />o.R TR /C+ryAi?OLRV�A�rD}.FrPARR T�ME+p2`t�T�FJ�F.,�Ui�/ UEP <br />CONFLICT O MTEREST POLIff STATE LENT <br />1. If you have answered, "yes' to any of the aforementioned items you are requiTed <br />to provide details for any transaction that exists. <br />2. If this statement fails to list a transaction that may exist that is non financial iu <br />nature, please attach details. <br />Details mwl include at least the name, and, address, or persons izvolved, and a <br />description of the relationship and the transaction. <br />Note-, failure to disclose any conflict of interest transaction that exists or is <br />potential within your private, nonprofit eutity nmy result iu the Department's <br />cessation of any further State fonds. <br />County:., Oran e <br />Agency's Name- <br />(1.cg€ l Applicant) Dis pute Settlement Center, Inc. <br />Federal Tax ® #: F561216584 <br />Private, Nonprofit <br />Entity Name: <br />Executive Director's Print <br />Nance: Sigz7, <br />_Dispute Settlement Center, Inc. <br />1~ lances Henderson - <br />Board Chair's print Matt <br />Name: Sign <br />Swann to and subscribed before xae on the <br />17ay of the date of said certifical:ion <br />ra,;,uie jVj,nr, <br />�NXBER <br />rllllirl, Il9, Y4l1���� <br />Fum D1JDP 13 001 Confl ict of interest Policy FOTM <br />Form strumue last revised OV2011 <br />North Carolina Department of Juvenile Justice and Do iuquency Prevention <br />(Date ofSignamm) <br />Page 3 of 3 <br />