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DocuSign Envelope ID:8C3AC364-20A8-477A-92A7-8FBD4923E2D0 <br /> DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON <br /> DISCRIMINATION CLAUSE <br /> Are any of the Board Members or employees of the agency which will be carrying out this <br /> program or members of their immediate families, or their business associates: <br /> Y_E_S. NQ <br /> a) Employees of or closely related to employees of the Town of Carrboro, the <br /> Town of Chapel Hill, or Orange County? <br /> b) Members of or closely related to members of the governing bodies of the Town <br /> of Carrboro, the Town of Chapel Hill, or Orange County? <br /> c) Current beneficiaries of the program for which funds are being requested? <br /> i <br /> d) Paid providers of goods or services to the program or having other financial <br /> interest in the program? <br /> 3 <br /> If you have answered YES to any question, please provide a full explanation below. <br /> i <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, <br /> handicap, religion, sexual orientation, gender identity/expression, familial status or veterans <br /> status with reference to any activities carried out by the grantee, no matter how remote. <br /> The parties hereto further agree in all respects to conform to the provision and intent of <br /> Orange County Civil Rights Ordinance, as amended and the Orange County Anti- <br /> discrimination Policy. This provision is enforced by action for specific performance, <br /> injunctive relief, or other remedy as by law provided; this provision shall be binding on the <br /> grantees,the successors and assigns of the parties hereto with reference to the above <br /> subject manner. <br /> I <br /> To the best of my knowledge and belief all of the above information is true and <br /> current. I acknowledge and understand that the existence of a potential conflict of <br /> interest does not necessarily make the program ineligible for funding, but the <br /> existence of an undisclosed conflia may-reG l ink -rmination of any <br /> -gran <br /> awarded. <br /> 0111 3/2 0 2 0 <br /> Signature: <br /> Executive Director Date <br /> Signature: <br /> 0111 3/2 0 2 0 <br /> --- <br /> Board Chairper n Date <br /> I <br /> Cover Page P a g e a 0 f 2 2 <br />