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DocuSign Envelope ID:7E3AF63A-2F47-4028-951A-OOBA2A7COOB2 - <br /> DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION 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 /> x❑ ❑ a) Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, <br /> or Orange County? <br /> ❑ x❑ b7 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 /> x❑ ❑c)Current beneficiaries of the program for which funds are being requested? <br /> ❑ x❑ d7 Paid providers of goads 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 /> a) One of our part-time residential staff members at HomeStart is an employee of the Orange County <br /> Health Department. <br /> c) Embracing a commitment to diversity and representation of all stakeholder perspectives; IFC has <br /> seats on our Board of Directors for shelter residents and other members of our programs. A member of <br /> our Board of Directors is currently a resident at Community House. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br /> hereto for themselves,their agents, officials, employees and servants agree not to discriminate in any <br /> manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual <br /> orientation, gender identity/expression, familial status or veterans status with reference to any <br /> activities Carried out by the grantee, no matter how remote. The parties hereto further agree in all <br /> respects to conform to the provision and intent of Orange County Civil Rights Ordinance, as amended <br /> and the Orange County Anti-discrimination Policy. This provision is enforced by action for specific <br /> performance, injunctive relief, or other remedy as by [aw provided; this provision shall be binding on <br /> the grantees, the successors and assigns of the parties hereto with reference to the above subject <br /> manner. <br /> To the best of my knowledge and belief all of the above information is true and current. I <br /> acknowledge and understand that the existence of a potential conflict of interest does not necessarily <br /> make the program'ineligible for funding, but the existence of an undisclosed conflict may result in the <br /> termination of any grant awarded. <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> o a rJ Chairperson Date <br /> _......-....... - — — <br /> Cover Page Page 5 ❑ f 20 <br />