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DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON- <br /> DISCRIMINATION CLAUSE <br /> Are any of the Board Members or employees of the organization which will be carrying out this project or their named <br /> project collaborators/partners or members of their immediate families,or their business associates... <br /> YES NO <br /> ❑ ® a)Employees of or closely related to employees of Orange County? <br /> ❑ ®b)Members of or closely related to members of the governing bodies of 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 interest in the program? <br /> If you have answered YES to any question or know of any other potential conflict of interest regarding your application, <br /> please provide a full explanation here: <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto for <br /> themselves,their agents,officials,employees and servants agree not to discriminate in any manner of these basis of <br /> race,color,gender,national origin,age,handicap,religion,sexual orientation,gender identity/expression, familial <br /> status or veterans status with reference to any activities carried out by the grantee, no matter how remote. The <br /> parties hereto further agree in all respects to conform to the provision and intent of Orange County Civil Rights <br /> Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced by action <br /> for specific 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 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 <br /> necessarily make the program ineligible for funding, but the existence of an undisclosed <br /> conflict may result in the termination of any irant awarded. <br /> Signature: <br /> Tfkvmaj &a&t <br /> Applicant's Authorized Signatory Date <br /> Page 3 of 17 <br />