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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 />☐X a) Employees of or closely related to employees of the Town of Carrboro, the Town of Chapel Hill, or <br />Orange County? <br />☐X b) Members of or closely related to members of the governing bodies of the Town of Carrboro, the <br />Town of Chapel Hill, or Orange County? <br />X ☐ c) Current beneficiaries of the program for which funds are being requested? <br />☐X 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 />As part of our commitment to resident leadership and engagement with organizational <br />direction, we have at least one current resident on the Board of Directors at all times. The <br />residents that serve on the Board can also be beneficiaries of the Resident Support <br />Program, but do not receive any direct monetary compensation through that program. <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 any <br />manner of these basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, <br />gender identity/expression, familial status or veterans status with reference to any activities carried <br />out by the grantee, no matter how remote. The parties hereto further agree in all respects to conform <br />to the provision and intent of Orange County Civil Rights Ordinance, as amended and the Orange <br />County Anti-discrimination Policy. This provision is enforced by action for specific performance, <br />injunctive relief, or other remedy as by law provided; this provision shall be binding on the grantees, <br />the successors and 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. I acknowledge <br />and understand that the existence of a potential conflict of interest does not necessarily make the <br />program ineligible for funding, but the existence of an undisclosed conflict may result in the termination of <br />any grant awarded. <br />Signature: <br />Executive Director Date <br />Signature: <br />Board Chairperson Date <br />Application Signatures: Please submit a wet signature or electronic signature,MS Word cursive fonts are not <br />acceptable. <br />Cover Page Page 8 of 24 <br />01/11/2023 <br />01/11/2023 <br />DocuSign Envelope ID: B7578AEA-ACB5-4FAD-8F8A-86A7F4B5A037