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DocuSign Envelope ID: FF2F034D-8ED9-46D3-BB8F-E4DD48CFCF88 <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 /> Z ❑ a) Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, <br /> or Orange County? <br /> ® ❑ b) Members of or closely related to members of the governing bodies of the Town of Carrboro,the <br /> 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 /> a) Board Member Pam Edwards's son lames T. Edwards III is a part-time employee with the Town of <br /> Carrboro, and her brother-in-law, Darrell Wall, is an employee with the Town of Chapel Hill. <br /> b) Board Member Amy E. Blanchard's husband Brian Hageman is a volunteer board member on the Chapel <br /> Hill Transit Board and the Carrboro Board of Adjustment. <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 law 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 /> LJ <br /> Signature: ) t C,c; <br /> Exelcytie Dire for Date <br /> Signature: <br /> Board Chair a son Date <br />