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DocuSign Envelope ID: A 1 EB25D0-1464-44DD-894A-53A04A225DF2 <br />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 <br />of their immediate families, or their business associates. <br />YES NO <br />181 D a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or <br />Orange County? <br />181 Cb) Members of or closely related to members of the governing bodies of the Town of Carrboro, the Town <br />of Chapel Hill, or Orange County? <br />D I&) Current beneficiaries of the program for which funds are being requested? <br />D 181d) 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 provide a full explanation below. <br />Assistant Chief Jabe Hunter is a member of the EMPOWERment, Inc. Board of Directors. He is <br />employed by the Town of Chapel Hill as an Assistant Chief of Police. Council members Tai Huynh and <br />Parris Miller are Ex-Oficio members of the El board. <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the pa rties hereto <br />for themselves, their agents, officials, employees, and servants agree not to discriminate in any manner <br />of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender <br />identity/expression, familial status or veterans' status with reference to any activities carried out by the <br />grantee, no matter how remote. The parties hereto further agree in all respects to conform to the <br />provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti- <br />discrimination Policy. This provision is enforced by action for specific performance, injunctive relief, or <br />other remedy as by law provided; this provision shall be binding on the grantees, the successors and <br />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. <br />acknowledge and understand that the existence of a potential conflict of interest does not necessarily <br />make the program ineligible for funding, but the existence of an undisclosed conflict may result in the <br />termination of any grant awarded. <br />lrOocuSlgned by: <br />Signature: ___ L,,_,l.).._~ .... 22""e2 .... c"'"306.,.E""A~""4:'"":'-~-------- <br />1/12/2022 <br />Exec~~ <br />Signature: __ __,L,_~~~aMl'.g1~2ct,j•,1,1,•c;.ac1.-1c~~liA._e..t,.1,vv ______ _ <br />Date <br />1/13 /20 2 2 <br />Board Chairperson Date <br />DocuSign Envelope ID: 7E3B840A-729F-4167-AA3E-B7E3D1B7700F