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DocuSign Envelope ID:675A1D41-4B16-4980-B798-628F35E22EDB r,i i•ACHMENT D <br /> CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY <br /> State of <br /> County v oiv1 f- <br /> Notary Public for said County and State, certify <br /> that <br /> e U�q ec--itn personally appeared before me this day and <br /> acknowledged <br /> that he/she is of <br /> C�l�f7l� f2 <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 15""' day of_ \ , <br /> Sworn to and subscribed before me this �5 day of <br /> q`0`````,` ,N„t i rrrrrrrrrr`f'fp <br /> F c� C) <br /> icial Seal) - Notar�<Pube <br /> PU�3v <br /> My Commission expires 201k , "G E O4,`t., <br /> err n�, <br /> ■■rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrru rrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrrr■ <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 /> ignature of Organization Official <br /> NCDHHS COI 1015 (Rev. 4/1 1) <br />