2018-475-E Finance - Piedmont Health Services Inc outside agency agreement

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DocuSign Envelope ID: CCFF6125- AA47- 438A- 98CA- B42519499D42 EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION d) DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE Are any of the Board Members or employees of the agency which will be carrying out this program or members of their immediate families, or their business associates... YES NO ❑ ® a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or Orange County? ❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town of Chapel Hill, or Orange County? 0 ❑ c) Current beneficiaries of the program for which funds are being requested? El ® d) Paid providers of goods or services to the program or having other financial interest in the program? If you have answered YES to any question, please provide a full explanation below. Please note that by Federal law, a majority of PHS Board members must be consumers of health care services at PHS. Consumer representation is a Federal requirement of Board membership to assure that services appropriately address community need. We now have five volunteer Board members who currently receive health care services at CCHC, although none are uninsured or currently in need of interpretation support (i.e. impacted by funding request). NON - DISCRIMINATION Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity /expression, familial status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, the successors and assigns of the parties hereto with reference to the above subject manner. To the best of my knowledge and belief all of the above information is true and current. I acknowledge and understand that the existence of a potential conflict of Interest does not necessarily make the program ineligible for funding, but the existence of an undisclosed conflict alt in the termination of anv arant awarded. Signature: Executive Direcloor Signature: Board Chairperson 1 1z-,-l( 2- CAS- Date Date AGENCY INFORMATION 1122/2018 1:34:09 PM Page 9 of 23