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1/24/24, 4:03 PM HSOA-24-5 <br />https://chapelhillnc.workflow.opengov.com/#/explore/records/62938/react-form-details/62938 18/19 <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 />N/A <br />Docusign Envelope ID: A5B4FFD3-9664-4EA0-9937-6709C85D11FD