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DocuSign Envelope ID:05AC53B6-D6A8-4C58-AE61-C861C28D8998 <br /> DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON DISCRIMINATION CLAUSE <br /> Are any of the Board Members or employees of the ngency which will be carrying out this program or <br /> members of their Immedlate fdmllles,or their business as%oclntns, <br /> YU N_Q <br /> ❑ N a)Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, <br /> or Orange County? <br /> ❑ El 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 /> ❑ M c)Current beneficiaries of the program for which funds are being requested? <br /> ❑ El 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 /> 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 orientation, <br /> gender identity/expression,familial status or veterans status with reference to any activities carried out <br /> by the grantee,no matter how remote. The parties hereto further agree in all respects to conform to <br /> the provision and Intent of Orange County Civil Rights Ordinance,as amended and the Orange County <br /> Anti-discrimination Policy. This provision Is enforced by action for specific performance, injunctive <br /> relief,or other remedy as by law provided;this provision shall be binding on the grantees,the successors <br /> and assigns of the parties hereto with reference to the above subject 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 can#Ilct may result In the <br /> termination of any grant awarded. <br /> Signature: _ 1 /131 20 9 0 <br /> Cu"v Irector DBtQ <br /> Signature: - ` =A$io <br /> Board Chairpers Date <br /> i 2 1 <br />