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DocuSign Envelope ID:650510CC-1 E40-4E7E-A21 D-3B96055FB69D <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 /> Z ❑ a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, <br /> or Orange County? <br /> 0 ❑ 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 /> ❑ 0 c) Current beneficiaries of the program for which funds are being requested? <br /> ❑ 0 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 /> Orange County Living Wage Steering Committee Member, Mark Marcoplos, is an Orange County <br /> Commissioner. OCLW Executive Director and Board Chairperson, Susan Romaine, is a Carrboro Town Council <br /> Member.As such, Mark and Susan are salaried employees of local government, <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto <br /> for themselves, their agents, officials, employees and servants agree not to discriminate in any manner of <br /> these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender <br /> identity/expression, familial status or veterans status with reference to any activities carried out by the <br /> grantee, no matter 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 County Anti-discrimination <br /> Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by <br /> law provided; this provision shall be binding on the grantees, the successors and assigns of the parties <br /> 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 /> terminations of any grant awarded. <br /> Signature: <br /> Executive Director Date <br /> Signature: �L1<tLL <br /> Board Chairperson Date <br />