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23 <br /> CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY <br /> State of <br /> County <br /> I, Notary Public for said County and State, certify <br /> that <br /> personally appeared before me this day and <br /> acknowledged <br /> that he/she is of <br /> [name of Organization] <br /> and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of <br /> Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held <br /> on the day of <br /> Sworn to and subscribed before me this day of <br /> (Official Seal) Notary Public <br /> My Commission expires 20 <br /> . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . <br /> Instruction for Organization: <br /> Sign and attach the following pages after adopted by the Board of Directors/Trustees or other <br /> governing body OR replace the following with the current adopted conflict of interest policy. <br /> Name of Organization <br /> Signature of Organization Official <br /> NCDHHS COT 10l 5 (Rev. 4/T T) <br />