Lake County Consortium
Revised 8/2018 1
Attachment 2: Conflict of Interest Certification
Instructions: please submit EITHER a “No Conflict” OR a “Potential Conflict” Certification Form.
No Conflict
The applicant organization/entity agrees to abide by the provisions of 2 CFR 200.112, 24 CFR 92.356,
and any referenced CFR provisions, or that of State and Local provisions with respect to conflicts of
interest, and covenants that it currently has no existing conflicts that warrant remedy under said
regulations. Specifically, under the development, ownership, sponsorship, and execution of projects or
programs, no organization or its officers, employees, agents, elected or appointed officials, or
consultants may occupy a HOME-assisted affordable housing unit. Additionally, the applicant
organization/entity and its officers, employees, agents, elected or appointed officials, or consultants
has no financial interest and shall not acquire financial interest or such benefit that would conflict in
any manner or degree with the performances of services required per this application or receipt of
HOME-financed agreements. Further, said persons shall not have an interest in any contracts,
subcontractors, or agreements as a result of this application for themselves or those with whom they
have family or business ties. Finally, no person outlined herein may acquire a financial interest or any
such benefit due to family or business ties to a known member, employee, agent, consultant, officer,
or elected or appointed official of the participating jurisdiction Lake County, or Consortium members
the City of North Chicago, and City of Waukegan, and all of the state of Illinois.
Federal Conflict of Interest Regulations shall apply to LCAHP funded projects.
Certification of Conflict of Interest:
This certification applies to the applicant organization/entity, and all its employees and members of
the Board of Directors, and any and all persons subscribed as having an interest in the
organization/entity.
The undersigned of _________________________________ (name of organization/entity) certifies to
the best of real knowledge that all employees and members of the governing Board of Directors is in
compliance with Conflict of Interest regulations as per 2 CFR 200.112, 24 CFR 92.356, and as
specifically described herein.
Legal Name of Applicant:
Signature:
Name and Title:
Date:
In the event the applicant organization/entity cannot certify compliance with 2 CFR 200.112
and/or 24 CFR 92.356 as required above, proceed to the following certification page.
