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					Please Note: No person who is an employee, agent, consultant, or officer of the Village of Athens or an elected or
appointed official, and who exercises or has exercised any functions or responsibilities with respect to activities related to
this Community Development Block Grant Fund Program, or who is in a position to participate in a decision making
process or gain inside information with regard to such activities, may obtain a personal or financial interest or benefit from
this program, or have an interest in any contract, subcontract or contract with respect thereto or the proceeds thereunder,
either for themselves or those with whom they have family or business ties, during their tenure.
.

                                           CONFLICT OF INTEREST
Do you have family or business ties to any of the following people? YES OR NO (please circle one)

If yes, disclose the nature of the relationship.

          Names of Covered Persons*                                                    Relationship
Charles Kornack, Village President
Lisa Czech, Village Clerk, Project Director
Glen Luetschwager, Committee Member
Dave Weiler, Committee Member
Jerome Tessmer, Committee Member
Anthony Kraft, Committee Member
Darrel Dehlinger, Project Specialist




*Covered persons includes any person who is an employee, agent, consultant, officer, or elected or appointed official, of the
grantee who exercises, or have exercised, any functions or responsibilities with respect to the CDBG housing activities, or who are
in a position to participate in a decision-making process or gain inside information with regard to housing activities, during their
tenure in the position or for one year thereafter.

The family is described as follows:

       Spouse                                                               Brothers and Brothers-in-Law
       Fiancée/Fiancé                                                       Anyone who receives more than 50% of their
       Children and Children-in-Law                                          support from the covered person (e.g., adopted
       Parents and Parents-in-Law                                            child, foster child)
       Sisters and Sisters-in-Law


    __________________________________________                                ______________________
    Signature                                                                   Date



    __________________________________________                                 _____________________
    Signature                                                                    Date




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