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1/16/24, 2:02 PM HSOA-24-49 <br />https://chapelhillnc.workflow.opengov.com/#/explore/records/62830/297526 12/14 <br />If you are not awarded a Community Impact Award, what would your agency’s funding request be? <br />Applicant Statement <br />Disclosure of Conflicts of Interest <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, current beneficiaries of the proposed <br />program for which funds are being requested? <br />No <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, members of or related to members of <br />the governing bodies of Chapel Hill, Carrboro, or <br />Orange County? <br />No <br />Are any board members or agency employees, <br />including their immediate relatives and business <br />associates, paid providers of goods or services to or <br />have other financial interest in the proposed <br />program? <br />No <br />Are any board members or employees, including <br />their immediate relatives and business associates, <br />related to employees of that Town of Chapel Hill, <br />Town of Carrboro, or Orange County? <br />No <br />If the answer to any of the above is yes, please provide an explanation. <br />Docusign Envelope ID: 24B21284-4C91-400A-B5A9-0EAB830F7C32