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tr <br />tr <br />tr <br />DISCLOSURE OF POTENTIAL CONF'LICTS 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/paftners or tnembers of their immediate families, or their business associates: <br />YES NO <br />f, a) Ernployees of or closely related to eurployees of Orange County? <br />ffi b) Vembers of or closely related to rnembers of the governing bodies of Orange Counq,? <br />ffi c) Current beneficiaries ofthe program for which funds are being requested? <br />n I a; laia providers ofgoods or services to the program or having other financial interest in the prograrn? <br />lf 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 />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 ofthe 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. 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 />Signature: <br />Signatory <br />Page 3 of 15 <br />DocuSign Envelope ID: 3B3ED7CA-61F5-4E47-87CD-95256B532A12