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DocuSign Envelope ID:480516C3-5BA1-4964-B7C5-9AA440382DBF <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 /> ❑ ® a) Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel Hill, <br /> or Orange County? <br /> ❑ ® 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 /> ❑ ® c) Current beneficiaries of the program for which funds are being requested? <br /> I-1 101 .J\ n—:,a .:,.I ,.r .. ...J.- .. +.. +6... r L.-...:.... ..+6.,.., fi..-......:-.I ...+... -+ :... 44, <br /> U � ul ralu prv'vlucl� ul guuu3 ur SciviCca w LIM prvgralil LJI Ilavrllg uulcl IJllall\,lal illI.cicx III Lite <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 <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 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: fL-• <br /> ` I { {?c �� I �l3I,Zy� <br /> irtarPresident�_�?. -- <br /> 11atP <br /> Signature: bttI <br /> ` Vice President Date <br /> Cover Page P a g e 8 o f 2 2 <br />