MSSNY Annual Conflict of Interest Statement

View the Conflict of Interest Policy Here

Name*

First NameLast Name

Please identify, the best of your knowledge, any and all entities of which you are an officer, director, trustee, member, owner or employee and with which MSSNY has a relationship (use N/A if appropriate):*

Please identify, to the best of your knowledge as an Officer, Trustee or Councilor of MSSNY, any and all transactions in which MSSNY is a participant and in which you have or might have a financial or personal interest (use N/A if appropriate):*

Have you or any Relative (as defined in the Conflict of Interest Policy) had or engaged in, or do you know of any other Covered Person that has engaged in, any of the following:*

	Yes	No
Direct or indirect interest (financial or otherwise) in a transaction, agreement or any other arrangement and in which MSSNY or any Affiliate of MSSNY participates?
Compensation arrangement or other interest in a transaction with MSSNY?
Compensation arrangement or other interest in or affiliation with any entity or individual that: (i) sells goods or services to, or purchases goods or services from MSSNY; (ii) competes with MSSNY; or (iii) with whom/which MSSNY has or is negotiating or contemplating negotiating any other transaction or arrangement?
Used your/their position or confidential information or MSSNY’s assets to your/their (or an affiliated party’s) personal advantage or for an improper or illegal purpose?
Solicited or accepted any gift or favor where such gift or favor might create the appearance of influence (other than gifts or favors of nominal value or tokens of respect or friendship unrelated to any transaction)?
Acquired any property or other rights in which MSSNY has, or you/they know or have reason to believe at the time of acquisition that MSSNY is likely to have an interest?
An opportunity related to the activities of MSSNY that is available to MSSNY or to you/them unless the Board has made an informed decision that MSSNY will not pursue that opportunity?
Indebtedness to MSSNY other than for amounts due for ordinary travel and expense advances?
Any other circumstances that may, in fact or in appearance, make it difficult for you/them to exercise independent, objective judgment or otherwise perform effectively?

If you answer yes to any of the above, please describe the relevant facts:

To Be Completed by Directors (of outside institution) Only:

	Yes	No
Have you been an employee of MSSNY or an Affiliate of MSSNY within the last three years?
Do you have a Relative who has been a Key Person of MSSNY or an Affiliate of MSSNY within the last three years?
Have you received and/or do you have a Relative who has received more than $10,000 in direct compensation from MSSNY or an Affiliate of MSSNY in any of the last three fiscal years (not including reasonable compensation or reimbursement for services as a director)?
Do you have a Financial Interest in and/or are you an employee of any entity that has made payments to or received payments from MSSNY or an Affiliate of MSSNY in excess of the lesser of (a) $25,000 or (b) 2% of such entity’s consolidated gross revenue over the last three years (which payments do not include charitable contributions)? If so, what is or was the nature of your Financial Interest or relationship?
Do you have a Relative who has a Financial Interest in and/or who is an officer of any entity that has made payments to or received payments from MSSNY or an Affiliate of MSSNY in excess of the lesser of (a) $25,000 or (b) 2% of such entity’s consolidated gross revenue over the last three years (which payments do not include charitable contributions)? If so, what is or was the nature of your Relative’s Financial Interest or relationship?
Are you a current owner, whether wholly or partially, director, officer or employee of MSSNY’s outside auditor or an entity that worked on MSSNY’s audit at any time during the past three years?
Do you have a Relative who is a current owner, whether wholly or partially, director, officer or employee of MSSNY’s outside auditor or an entity that has worked on MSSNY’s audit at any time during the past three years?

If you answer yes to any of the foregoing, please describe the relevant facts:

The answers to the foregoing questions are stated to the best of my knowledge and belief.

I also acknowledge that I have received a copy of, read and understood the conflict of interest policy and agree that I have adhered and will continue to adhere to such policies.

Additionally, I understand that in order to maintain its status as a not for profit corporation, MSSNY must engage in activities that accomplish one or more of the purposes for which it was formed as a not for profit corporation.

Date:*

Date

Signature:*