Annual Disclosure of Conflict of Interest Form

Conflicts of Interest Disclosures. 

If applicable, I have described above (a) the names of the entities with which the Company has an existing or proposed relationship and of which I am, or, to the best of my knowledge, any family member, key customer, or client is, an officer, director, trustee, member, owner (either as a sole proprietor, shareholder, member, partner or otherwise) or employee, (b) any transaction in which the Company is a participant with such entities and in which I might have a conflicting interest, and (c)1 any relationships, positions or circumstances in which I am involved that I believe may constitute a financial interest or material nonfinancial interest, as those terms are defined in the Conflict of Interest Policy of the Company, in a person, entity or organization with which the Company has or proposes to have a transaction.

1. This definition tracks the disclosure requirements of Section 75(C) of the Revitalization Act.

B.   Certifications.   I hereby acknowledge that I:  

have received, read and understand, and agree to comply with, the Conflicts of Interest Policy of the Company (the “Policy”),
understand that the Company is charitable and in order for the Company to maintain any federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes, shall not use my position, or the knowledge (including any confidential information) gained from my position to further my own financial interests or the interests of any other person by whom I am employed or retained or with whom I have any other affiliation or to derive financial advantage, and may not obtain for me, my relatives (including but not limited to family members) or my employer (or others with whom I am affiliated) a material financial interest of any kind from my association with the Company (this does not preclude the receipt of reasonable compensation for services rendered to the Company),
have a duty to place the interest of the Company foremost in any dealings with the Company decision-making, shall not conduct personal business with the Company and any of its affiliates, without prior disclosure and approval, will report a personal interest in any proposed transaction with the Company in the form of a personal financial interest or material nonfinancial interest in the transaction or in any organization involved in the transaction, or in holding a position as trustee, director, or officer in any such organization, and will make full disclosure of such interest in writing before any discussion or negotiation of such transaction,
do not have any right to be present for discussions or votes on whether any potential conflict of interest with respect to any matter coming before the Board or committee constitutes a conflict of interest, shall exercise care not to disclose confidential information acquired in connection with such status or information, the disclosure of which may harm the interest of the Company or which would result in personal profit or advantage for me, my family members, any employer or other person with whom I am affiliated, and understand that any activity that I engage in related to the Company that may cause problems for the Company, seeming or real, shall be disclosed to the Company prior to such action occurring.