CH ___________ DATE _____________
DTN __________
ANNUAL CERTIFICATION OF COMPLIANCE WITH
CONFLICT OF INTEREST POLICY (sample)
Pursuant to s. 496.4055(2), Florida Statutes, ______________________________ has
(Name of Organization/Sponsor)
adopted a policy regarding conflict of interest transactions. All directors, officers, and
trustees of the charitable organization hereby certify compliance with the adopted policy.
NAME SIGNATURE DATE
1. __________________________ ___________________________ ____________
2. __________________________ ___________________________ ____________
3. __________________________ ___________________________ ____________
4. __________________________ ___________________________ ____________
5. __________________________ ___________________________ ___________
6. __________________________ ___________________________ ____________
7. __________________________ ___________________________ ____________
8. __________________________ ___________________________ ____________
9. __________________________ ___________________________ ____________
10. __________________________ ___________________________ ____________
11. __________________________ ___________________________ ____________
12. __________________________ ___________________________ ____________
13. __________________________ ___________________________ ____________
14. __________________________ ___________________________ ____________
15. __________________________ ___________________________ ____________
16. __________________________ ___________________________ ____________
(continue on additional pages if necessary)