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Docusign Envelope ID: B585AFF7-3200-4914-9ADB-7BC32036B13D <br /> CONFLICT OF INTEREST ACKNOWLEDGEMENT AND POLICY <br /> State of <br /> County ji.,/(t 14,64 W <br /> I, L .G P� Notary Public for said County and State, certify <br /> that <br /> . f G� J4pc personally appeared before me this day and <br /> acknowledged 61 <br /> that he/she is eP of <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 day of I�` 7 <br /> Sworn to and subscribed before me this _day of &Uyd <br /> (Official Seal) Not ublig <br /> My Commission expires1 20 9D <br /> minnnimnuquuunnimuuiuuniuimunrninnnnminwumgiinnuumnnuwouuuuUnnmmunuuumnnunnnnuuunalnnnannuununuumnnnnmmmmnnumwmnnunNwmunmnunmuwumunuuNpnuuuquuulpuilin <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 /> f��-0-04 A 0'"'- \,, c <br /> Name of Or anization <br /> �j <br /> Sign r anization Offic <br /> NCDI-IFiS C011015 (Rev.4/11) <br />