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P a g e 3 o f 18 <br /> <br />DISCLOSURE OF POTENTIAL CONFLICTS OF INTEREST AND NON-DISCRIMINATION CLAUSE <br /> <br />Are any of the Board Members or employees of the organization which will be carrying out this project or <br />their named project collaborators/partners or members of their immediate families, or their business <br />associates: <br /> <br />YES NO <br /> <br /> a) Employees of or closely related to employees of Orange County? <br /> <br /> b) Members of or closely related to members of the governing bodies of 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 interest in the <br />program? <br /> <br />If you have answered YES to any question or know of any other potential conflict of interest regarding your <br />application, please provide a full explanation here: <br /> <br />n/a <br /> <br />NON-DISCRIMINATION <br /> <br />Provider agrees as part of consideration of the granting of funds by funding agencies to the parties hereto <br />for themselves, their agents, officials, employees and servants agree not to discriminate in any manner on <br />the basis of race, color, gender, national origin, age, handicap, religion, sexual orientation, gender <br />identity/expression, familial status or veteran 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 provision <br />and intent of Orange County Civil Rights Ordinance, as amended and the Orange County Anti-Discrimination <br />Policy. This provision is enforced by action for specific performance, injunctive relief, or other remedy as by <br />law provided; this provision shall be binding on the grantees, the successors and assigns of the parties <br />hereto with reference to the above subject manner. <br /> <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 <br />of any grant awarded. <br /> <br /> <br />Signature: August 18, 2023 <br /> Applicant’s Authorized Signatory Date <br /> <br />DocuSign Envelope ID: DBE8454E-5CDD-4377-A739-3C0016853D4E