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— DocuSign Envelope ID:8173BBCF-1050-4110-B8C4-4622BA864EOB <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 /> Z ❑bj 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 /> ❑ Z cj 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 /> Susan Romaine is a Founder and Director of PORCH Chapel Hill-Carrboro and Chair of the Board of Directors. <br /> She was recently elected to the Town Council of Carrboro. Susan does not directly administer the program <br /> for which we are seeking funding. <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,`i 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 /> Signature: <br /> cutive Direct Date <br /> >�Signature: / <br /> Board Chairperson Date' <br />