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P a g e 3 o f 19 <br /> <br />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 /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of Orange County? Unknown* <br /> <br /> b) Members of or closely related to members of the governing bodies of Orange County? Unknown* <br /> <br /> c) Current beneficiaries of the program for which funds are being requested? <br /> <br /> d) Paid providers of goods or services to the program or having other financial interest in the program? <br /> <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 /> <br />*The Town does not keep any records or documentation which would provide the information needed to answer <br />questions a) and b). <br /> <br /> <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 /> <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 grant awarded. <br /> <br /> <br />Signature: 7-30-21 <br /> Applicant’s Authorized Signatory Date <br /> <br /> <br />DocuSign Envelope ID: 925D6FBC-24A8-425B-8158-E760CA6EAD2A