Conflict of Interest Statement
Note: A “related party” (as defined in the policy) is (i) a family member, or (ii) a business or organization of which the person signing this statement or a family member (x) owns or expects to own, directly or indirectly, more than a 5% interest (whether as a stockholder, partner, trustee or other owner), (y) has a beneficial interest in a trust that owns directly or indirectly more than a 5% interest, or (z) is a director, officer, or employee. A “family member” is a parent (or more remote ancestor), spouse, brother, sister, spouse of a brother or sister, child, step-child, grandchild, great-grandchild or a spouse of a child, step-child, grandchild or great-grandchild of the person signing this statement.
Fill in the blanks below: As board member of Real Life Families (the “Organization”), I, _________________ ______________________________, acknowledge that I: received a copy of the Organization’s Conflict of Interest Policy dated ___________________________; read and understood the policy; agree to comply with the spirit and intent of the policy and will disclose any potential conflicts, other than those stated below, as they may arise before completion of my next conflict of interest statement; and understand that the Organization is a charitable organization and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes. *
Based on a review of the Organization’s Conflict of Interest Policy, are you aware of any interest that you or a related person may have that could give rise to a conflict of interest? If yes, please complete the questions below. *
Please list all relationships (if any) between you or a “related party” (as defined above) with the Organization that involve an actual or potential financial benefit to you or the related party or that otherwise may represent a conflict of interest within the spirit and intent of the policy. Include an estimate of the related actual or potential financial benefit.
Please list any business dealings during the past year (or, if applicable, since your last submission of this Conflict of Interest Statement) of which you are aware in which you or a “related party” (as defined above) have received any salary, gifts or loans from any source from which the Organization obtains goods or services or otherwise has business dealings:
Please list any potential or pending transaction to which the Organization is a party and in which you or a “related party” (as defined above) has a direct or indirect interest:
By typing your name below you are agreeing to this statement: My answers above are accurately stated to my knowledge and belief. *
Date *
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