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DocuSign Envelope ID:789E95FE-A609-46D6-AEOC-EDB3D189AD23 <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 <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) Tvlembers 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 /> 0 ®c) Current beneficiaries of the program for which funds are being requested? <br /> ❑.. Z.d) PaJd providers of goods or services to the program or having other financial interest in the <br /> „'grogram? <br /> If you:hwe answered.YES to any question, please provide a full explanation below. <br /> ....NON-DISCRIMI NATION <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;thee.best of my knowledge and belief all of the above information is true and current. I <br /> acknowledge'ar d undeestand that the existence of a potential conflict of interest does not necessarily <br /> hake#hb�ro&jm'ineligible:for funding, but the existence of an undisclosed conflict may result in the <br /> termination of any grant awarded. <br /> •J i . <br /> Signature: ICJ 1, f 1�o aZn <br /> Executive Director Date ( j <br /> Signature: <br /> 0 1 zo z_0 <br /> Bo; rd C airperson Date <br /> aver'Page Page 3 o i 14 <br /> - s <br /> • •..ram.m..r.�.. ;.. .w.-....T ,... �..'., ..... .. .. ..,.,® ,..,.....Y . , <br />