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To the best of my knowledge and belief all information and data in this <br />application is true and current. The document has been duly authorized by <br />the governing board of the applicant. <br /> <br /> <br />Signature: <br /> Executive Director Date 1/5/2022 <br /> <br /> <br />Signature: <br /> Board Chairperson Date 1/5/2022 <br /> <br /> <br /> <br />DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND <br />NON-DISCRIMINATION CLAUSE <br />Are any of the Board Members or employees of the agency which will be carrying out <br />this program 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 the Town of Carrboro, the <br />Town of Chapel Hill, or Orange County? <br /> <br />☐ ☒ b) Members of or closely related to members of the governing bodies of the <br />Town of Carrboro, the Town of Chapel Hill, or Orange County? <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 <br />interest in the program? <br />If you have answered YES to any question, please provide a full explanation below . <br />c) CEF has incorporated into our By-Laws the requirement that at least one former or <br />current beneficiary (Member) of our program serve on the Board of Directors at all <br />times. Currently, two Members serve on the Board of Directors. These members of the <br />Board of Directors provide invaluable advice based on their particular experiences <br />working with the organization directly, and like all members of the Board of Directors, <br />sign an annual conflict of interest disclosure outlining any potential conflicts that may <br />arise based on their dual relationship with the organization. <br /> <br />Cover Page Page 8 of 30 <br /> <br />DocuSign Envelope ID: 6B366C4A-0FD9-4CC3-82A7-F7842568D4BD