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DocuSign Envelope ID: A899BE5E- BAEC- 40F3 -91 E1- A9D77FC4C488 <br />FIPTETC C�RLIC�SUOFINTTd) DISCLOSURE ONIAF ERESANVMNTRMINATION <br />CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out this program 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 Carrboro, the Town of Chapel <br />Hill, or Orange County? <br />❑ ® b) Members of or closely related to members of the governing bodies of the Town of Carrboro, <br />the Town of Chapel Hill, or Orange County? <br />❑ ® c) Current beneficiaries of the program for which funds are being requested? <br />❑ ® 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 />NON - DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the <br />parties hereto for themselves, their agents, officials, employees and servants agree not to <br />discriminate in any manner of these basis of race, color, gender, national origin, age, handicap, <br />religion, aexual orieritation, gerider'ideiititylexpre5sion, familial statds' or veterahs stafias wIt - <br />reference to any activities carried out by the grantee, no matter how remote. The parties hereto <br />further agree in all respects to conform to the provision and intent of Orange County Civil Rights <br />Ordinance, as amended and the Orange County Anti - discrimination Policy. This provision is <br />enforced by action for specific performance, injunctive relief, or other remedy as by law <br />provided; this provision shall be binding on the grantees, the successors and assigns of the <br />parties hereto with reference to the above subject manner. <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 program ineligible for funding, but the existence of an undisclosed <br />conflict may result in the termination of any grant awarded. <br />Signature: �( <br />Executive Director <br />Signature: <br />oard Chairperson <br />1/22/2018 <br />Date <br />112212018 <br />Date <br />AGENCY INFORMATION 1122/2018 10:14:21 AM Page 4 of 33 <br />