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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 members of their <br /> immed late families,or their business associates. <br /> YES NO <br /> ❑ X a) Employees of or closely related to em "loyees of the Town of Carrboro, the Town of Chapel Hill, or Orange <br /> County? <br /> ❑ X b) Members of or closely related to men bers of the governing bodies of the Town of Carrboro,the Town of <br /> 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 program? <br /> If you have answered YES to any question, please prx vide a full explanation below. <br /> NON-DISCRIMINATION <br /> Provider agrees as part of consideration of t e granting of funds by funding agencies to the parties hereto for <br /> themselves, their agents,officials,employeesInd servants agree not to discriminate in any manner of these basis <br /> of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender identity/expression, <br /> familial status or veterans status with refer4ce to any activities carried out by the grantee, no matter how <br /> remote. The parties hereto further agree in all respects to conform to the provision and intent of Orange County <br /> Civil Rights Ordinance, as amended and the Orange County Anti-discrimination Policy. This provision is enforced <br /> by action for specific performance, Injunctive relief, or other remedy as by law provided; this provision shall be <br /> binding on 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 acknowledge and <br /> understand that the existence of a potential conflict of Interest does not necessarily make the program ineligible for <br /> funding, but the existence of an undisclosed conflict may result in the termination of any grant awarded. <br /> Signature: /X Qn.e , -7P7 ` & l Zz> Z Z <br /> Executive D' Date rrl� <br /> Signature: <br /> Bow <br /> Cover Page Page 5 of 21 <br />