Fillable Conflict of Interest Disclosure Form Oregon Government Ethics (Oregon Department of Education Early Learning Division)

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Conflict of Interest Disclosure Form Oregon Government Ethics (Oregon Department of Education Early Learning Division)

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Conflict of Interest Disclosure Form
Oregon Government Ethics law identifies and defines two types of conflicts of interest, actual and potential.
An actual conflict of interest is defined in ORS 244
.020(1) and a potential conflict of interest is defined in
ORS 244.020(13).
Potential Conflict of Interest
A public official—including participants in this review process—is met with a potential conflict of interest
when the public official participates in actions that could affect the financial interests of the official, the
official’s relatives or a business with which the official or a relative of the official is associated. Individuals
with a potential conflict of interest may participate in the review process after declaring the potential
conflict. The disclosure must be stated publicly at the meeting and recorded in the committee’s minutes.
Independent Reviewers must attest by written declaration that no potential (or actual) conflict exists
regarding the application for which they are reviewing.
Actual Conflict of Interest
An actual conflict of interest exists when a public official participates in actions that would affect the
financial interests of the official, the official’s relative or a business with which the official or a relative of
the official is associated. Those with an actual conflict of interest regarding matters before this review
process may not participate.
Date:
Name:
Position:
Please describe below any relationships, transactions, positions you hold (volunteer or otherwise), or
circumstances that you believe could contribute to a conflict of interest:
_ _ I have no conflict of interest to report.
_ I have the following conflict of interest to report (please specify other nonprofit and for-profit
boards you (and your relative) sit on, any for-profit businesses for which you or an immediate family
member are an officer or director, or a majority shareholder, and the name of your employer and any
businesses you or a family member own:
1.
2.
I hereby certify that the information set forth above is true and complete to the best of my knowledge.
Signature:
Date:
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Conflict of Interest Disclosure Form Oregon Government Ethics (Oregon Department of Education Early Learning Division)

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Completed 28 June 2021

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