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DocuSign Envelope ID:8C3F60DE-6E3D-42CA-B364-FB7D449BBC74 <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 /> ❑ X a) Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, <br /> or Orange County? <br /> ❑ X. 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 /> ❑ X c)Current beneficiaries of the program for which funds are being requested? <br /> ❑ X. 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 conflict may result in the <br /> termination of any grant awarded. <br /> Signature: e 41L. / ,/ I�/ �2a <br /> Executive Director Date <br /> Signature: / <br /> ,01"43ard Chairperson Date <br /> Cover Page P a g e 8 o f 2 3 <br />