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1/30/24, 2:24 PM HSOA-24-48 <br />https://chapelhillnc.workflow.opengov.com/#/explore/records/63424/react-form-details/63424 17/17 <br />Applicant Statement <br />To the best of my knowledge and belief all of the above information is true and <br />current. I acknowledge and understand that the existence of a potential conflict of <br />interest does not necessarily make the program ineligible for funding, but the <br />existence of an undisclosed conflict may result in the termination of any grant <br />awarded. <br />Name of Person Submitting the Application <br />Tova Hairston <br />Agency Role of Person Submitting the Application <br />Executive Director <br />Agency Representative Signature <br />Tova Hairston <br />Jan 12, 2024 <br />By submitting this application, the agency representative noted above affirms <br />they are either the Executive Director, or, if someone other than the Executive <br />Director is submitting this application, they affirm the Executive Director has <br />reviewed the application for accuracy and approved it for submittal. <br />Approval Details <br />Approved Amount <br />– <br />Docusign Envelope ID: 1E46DA1E-0260-4212-A023-FEA4EE5C1439