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DocuSign Envelope ID:A2DC2EF9-6C9A-438D-A97D-84CEA493644C <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 /> YES NO <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 /> ® d) Paid providers of goods or services to the program or having other financial <br /> interest in the program? <br /> If you have answered YES to any question, please provide a full explanation below. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to <br /> the parties hereto for themselves, their agents, officials, employees and servants agree <br /> not to discriminate in any manner of these basis of race, color, gender, national origin, <br /> age, handicap, religion, sexual orientation, gender identity/expression, familial status or <br /> veterans status with reference to any activities carried out by the grantee, no matter <br /> how remote. The parties hereto further agree in all respects to conform to the provision <br /> and intent of Orange County Civil Rights Ordinance, as amended and the Orange <br /> 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 <br /> be binding on the grantees, the successors and assigns of the parties hereto with <br /> reference to the above subject manner. <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 conflict may result in the termination of any grant <br /> awarded. <br /> Signature: �" ` 1/13/2020 <br /> Executive Director Date <br /> Signature: 1/13/2020 <br /> Cover Page P a g e 8 o f 2 5 <br />