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Cover Page P a g e 12 o f 55 <br /> <br />remedy as by law provided; this provision shall be binding on the grantees, the <br />successors and assigns of the parties hereto with reference to the above subject <br />manner. <br /> <br />To the best of my knowledge and belief all of the above information is true and <br />current. I acknowledge and understand that the existence of a potential conflict <br />of interest does not necessarily make the program ineligible for funding, but the <br />existence of an undisclosed conflict may result in the termination of any grant <br />awarded. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />Signature: 1/14/2021 <br /> Executive Director Date <br /> <br /> <br /> <br /> <br /> <br />Signature: 1/14/2021 <br /> Board Chairperson Date <br /> <br />EXHIBIT A: PROVIDER'S OUTSIDE AGENCY APPLICATION <br />DocuSign Envelope ID: 11DA72B8-CC83-439E-A25C-F64DE607C614