CONFLICT OF INTEREST DISCLOSURE CERTIFICATE

SERC-NAHRO Regional officers, members of its Board of Governors, and senior members of its professional staff are required by SERC-NAHRO policy to complete and file annually a certification concerning real or apparent conflicts of interest. Please complete and file this certificate with the President on or before January 31st of the year of filing.

For purposes of completing this certificate: A conflict of interest arises when a person who is in a position of authority over SERC-NAHRO, its activities or its employees may benefit financially from a decision such person must or could make in his or her capacity as a SERC-NAHRO official or employee. This includes indirect benefits, such as benefits to family members, businesses in which the official or employee or a family member has an ownership or contractual interest or other material relationship, or benefits to other persons with whom the official or employee has a relationship that is not an arms length relationship.

SERC-NAHRO officials and employees are expected to avoid both real conflicts of interest and actions that result in the appearance of such a conflict. Using the above-stated definition as a guide, please indicate the following (Attach a separate sheet if additional space is necessary to provide adequate detail).

The following are all interests, relationships or activities held or engaged in by the undersigned that give rise to a present conflict of interest relating to SERC-NAHRO (Please state “none” if none):*

YesNone

Comment:

The following are all interests, relationships or activities held or engaged in by the undersigned that in the good faith judgment of the undersigned, could give rise to a conflict of interest within the 12-month period following the date of this Certificate (Please state “none” if none):*

YesNone

Comment:

The following are all interests, relationships or other activities of the undersigned that presently do, or reasonably will, in the 12-month period following the date of this Certificate, give rise to an apparent conflict of interest or an appearance of impropriety, as distinguished from an actual conflict of interest.(Please state “none” if none.)*

YesNone

Comment:

I hereby certify that the above statements are true, correct, and complete.

Signature:*

Print Name:*

SERC-NAHRO Position (Office, Board Member, Employee Position)*

Date*

Date

Please Note: Matters revealing conflicts may be disclosed to the Board of Governors and appropriate action may be requested to mitigate the effect of or resolve the conflict.