Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: Name of Organization Signature of Organization Official Date State of North Carolina County of I, , Notary Public for said County and State, certify that personally appeared before me this day and acknowledged that he/she is of [enter name of entity] and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the day of , . Sworn to and subscribed before me this day of , . (Official Seal) Notary Public My Commission expires , 20 To: Davidson County Department of Social Services I certify that Xxxxxx X. Xxxxx does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. I further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S. 143C-10-1b. Xxxxxx X. Xxxxx being duly sworn, say that I am owner and manager of Xxxxxx X. Xxxxx, a professional association engaged in the practice of law in Wallburg in the State of North Carolina and that the foregoing certification is true, accurate and complete to the best of my knowledge and was made and subscribed by me. I also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Xxxxxx X. Xxxxx Date STATE OF County I, , certify that personally appeared before me this day and acknowledged the execution of the foregoing document(s) and being duly sworn to (or affirmed) by me that said document was signed by him/her in front of me. Witness my hand and seal this the day of . Sworn to and subsc...

Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: Name of Organization Signature of Organization Official Date State of North Carolina County of I, , Notary Public for said County and State, certify that personally appeared before me this day and acknowledged that he/she is of [enter name of entity] and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the day of , . Sworn to and subscribed before me this day of , . (Official Seal) Notary Public My Commission expires , 20 Instructions: Grantee/Provider should complete this certification for all funds received. Entity should enter appropriate data in the yellow highlighted areas. The completed and signed form must be provided to the Davidson County Department of Social Services. We certify that the [insert organization’s name] does not have any overdue tax debts, as defined by N.C.G.S. 105-243.1, at the federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. 143C-6-23(c) is guilty of a criminal offense punishable as provided by N.C.G.S.) 143C-10-1b. [Name of Board Chair] and [Name of Second Authorizing Official] being duly sworn, say that we are the Board Chair and [Title of the Second Authorizing Official], respectively, of [insert name of organization] of [City] in the State of [Name of State]; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Board Chair [Title...

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Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain:

Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Certification: Sworn Statement: (1) No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any Federal, state or local government agency, a Member of Congress, a Member of the General Assembly, an officer or employee of Congress, an officer or employee of the General Assembly, an employee of a Member of Congress, or an employee of a Member of the General Assembly in connection with the awarding of any Federal or state contract, the making of any Federal or state grant, the making of any Federal or state loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative agreement. (2) If any funds other than Federal appropriated funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any Federal, state or local government agency, a Member of Congress, a Member of the General Assembly, an officer or employee of Congress, an officer or employee of the General Assembly, an employee of a Member of Congress, or an employee of a Member of the General Assembly in connection with the awarding of any Federal or state contract, the making of any Federal or state grant, the making of any Federal or state loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any Federal or state contract, grant, loan, or cooperative agreement, the undersigned shall complete and submit Standard Form LLL, "Disclosure Form to Report Lobbying," in accordance with its instructio...

Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. Approved by: _______________________________________ Legal Name of Organization _______________________________________ Signature of Organization Official _______________________________________ Title of Organization Official _______________________________________ Date We, the undersigned entity, hereby testify that the 501 (c)(3) status is on file with the North Carolina Department of Health and Human Services and is still in effect. __________________________________________________________________ Name of Entity __________________________________________________________________ Signature of Chairman, Executive Director, or other authorized official ________________________________________________________ Title of above signed authorized official Sworn to and subscribed before me this ______ day of __________________, 20____ ___________________________________ Notary Signature and Seal Notary’s commission expires ____________________, 20 ___.

Record of Conflict. The minutes of the governing board and all committees with board delegated powers shall contain: 1. The names of the persons who disclosed or otherwise were found to have an actual or possible conflict of interest, the nature of the conflict of interest, any action taken to determine whether a conflict of interest was present, and the governing board's or committee's decision as to whether a conflict of interest in fact existed. 2. The names of the persons who were present for discussions and votes relating to the transaction or arrangement that presents a possible conflict of interest, the content of the discussion, including any alternatives to the transaction or arrangement, and a record of any votes taken in connection with the proceedings. . Approved by: Name of Organization Signature of Organization Official Date State of North Carolina County of I, , Notary Public for said County and State, certify that that he/she is of [enter name of entity] and by that authority duly given and as the act of the Organization, affirmed that the foregoing Conflict of Interest Policy was adopted by the Board of Directors/Trustees or other governing body in a meeting held on the day of , . Sworn to and subscribed before me this day of , . (Official Seal) Notary Public My Commission expires , 20 To: THE GUILFORD COUNTY DEPARTMENT OF HEALTH AND HUMAN SERVICES We hereby certify that ONE-SOURCE OF THE CAROLINAS, LLC. does not have any overdue tax debts, as defined by N.C.G.S. §105-243.1, at the Federal, State, or local level. We further understand that any person who makes a false statement in violation of N.C.G.S. §143-6.2(b2) is guilty of a criminal offense punishable as provided by N.C.G.S. §143- 34(b). being duly sworn, say that we are the Board Chair and the , respectively, of ONE-SOURCE OF THE CAROLINAS, LLC. in the (Title of the Second Authorizing Official) Of , in the State of North Carolina; and that the foregoing certification is true, accurate and complete to the best of our knowledge and was made and subscribed by us. We also acknowledge and understand that any misuse of State funds will be reported to the appropriate authorities for further action. Sworn to and subscribed before me on the day of the date of said certification. Public Law 103-227, Part C-Environmental Tobacco Smoke, also known as the Pro-Children Act of 1994 (Act), requires that smoking not be permitted in any portion of any indoor facility owned or leased or contracted for by an entity and us...

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