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Ai ioka Counrty <br /> WkWNE ,SOTA <br /> CONFLICT OFINTEREST <br /> As an applicant requesting funding,will any of your employees, agents, consultants,officers, or elected <br /> officials experience any of the following conflicts of interest: <br /> 0 Yes M No Participate in the decision maldng process for the approval of this application? <br /> (i.e., an Anoka County Commissioner or HRA Trustee) <br /> El Yes Z No Have a financial interest or reap a financial benefit from this program/activity? <br /> Yes M No Han an int est in any contract, subcontract, or agreement with respect to this <br /> application either for themselves or those with whom they have family or <br /> business ties during the program year and for one year thereafter? <br /> *If you selected, "yes," to any of the above, clearly describe the conflict below: <br /> ........................ ......................................... ........................................................... ...................-.... ........ ...................................... <br /> . ....................................................--.1111111111... ........ ................'I',,,,',,,,,',,,. .. ................ ........................................ . ................................. <br /> OFFICE USE ONLY <br /> Sam.gov debarment check completed by: ................................................. <br /> I:::::1 Applicant/Organization <br /> Top organizational executive <br /> Contractors/Subcontractors <br /> 16 <br />