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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 <br />members of their immediate families, or their business associates. <br />YES NO <br />☐☒a)Employees of or closely related to employees of the Town of Carrboro,the Town of Chapel <br />Hill, or Orange County? <br />☐☒b)Members of or closely related to members of the governing bodies of the Town of Carrboro, <br />the Town of Chapel Hill, or Orange County? <br />☐ ☒ c) Current beneficiaries of the program for which funds are being requested? <br />☐☒d)Paid providers of goods or services to the program or having other financial interest in the <br />program? <br />If you have answered YES to any question,please provide a full explanation below. <br />NON-DISCRIMINATION <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the parties <br />hereto for themselves,their agents,officials,employees and servants agree not to discriminate in <br />any manner of these basis of race,color,gender,national origin,age,handicap,religion,sexual <br />orientation,gender identity/expression,familial status or veterans status with reference to any <br />activities carried out by the grantee,no matter how remote. The parties hereto further agree in all <br />respects to conform to the provision and intent of Orange County Civil Rights Ordinance,as <br />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 <br />be binding on the grantees,the successors and assigns of the parties hereto with reference to the <br />above subject manner. <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 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 />Cover Page Page 6 of 20 <br />DocuSign Envelope ID: AF51EA21-1E75-4247-A4BF-4A60BCBE6049