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1/30/24, 4:17 PM HSOA-24-43 <br />https://chapelhillnc.workflow.opengov.com/#/explore/records/62828/react-form-details/62828 17/18 <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 />Non-discrimination Clause <br />Provider agrees as part of consideration of the granting of funds by funding agencies <br />to the parties hereto for themselves,their agents, officials,employees and servants <br />agree not to discriminate in any manner of these basis of race, color, gender, national <br />origin, age, handicap,religion,sexual orientation,gender identity/expression,familial <br />status or veterans status with reference to any activities carried out by the grantee, <br />no matter how remote.The parties hereto further agree in all respects to conform to <br />the provision and intent of Orange County Civil Rights Ordinance,as amended, and <br />the Orange County Anti-discrimination Policy. This provision is enforced by action for <br />specific performance,injunctive relief,or other remedy as by law provided; this <br />provision shall be binding on the grantees,the successors and assigns of the parties <br />hereto with reference to the above subject manner. <br />Docusign Envelope ID: F9E3EFAB-16FA-4281-B2B8-12C1DD0C3608