CO
NFLICT OF INTEREST DISCLOSURE FORM
Conflict of Interest Regulation. No persons who exercise or have exercised any functions or responsibilities with respect
to activities assisted with federal funds or who are in a position to participate in a decision making process or gain inside
information with regard to these activities, may obtain a financial interest or benefit from an assisted activity, or have an
interest in any contract, subcontract or agreement with respect thereto, or the proceeds there under, either for themselves or
those with whom they have family or business ties, during their tenure or for one year thereafter.
Name: ____________________________________ Program Name: _____________________________________
Add
ress: ____________________________________ Program Client #: __________________________________
Ci
ty, State, Zip: _____________________________ Contractor/Vendor#: ____________________________
The purpose of this document is to assist in the determination of whether additional restrictions, oversight, or other conditions
might be advisable prior to execution of any contract, funding or providing assistance. The term “Conflict Of Interest” refers to
situations in which financial or other personal considerations may compromise, or have the appearance of compromising
professional judgment in following the rules and regulations of the program. Please check the appropriate box for each question
and complete the attachment if indicated. This form (with Attachments, if required) must be completed and returned to your
Program Representative.
A. Fa
mily Relationships:
Do you have a family member directly or indirectly involved or employed with YOUR ORGANIZATION that creates a conflict
of interest or the appearance of a conflict under the Conflict of Interest Regulation provided above?
Y
ES NO (if YES, please complete Part A of the Attachment)
B. P
rogram Relationships:
Are you involved in any other activity directly or indirectly with YOUR ORGANIZATION that may create a conflict of interest
or the appearance of a conflict under the Conflict of Interest Regulation provided above?
Y
ES NO ( if YES, please complete Part B of the Attachment)
C.
Business Relationships:
Are you or a family member (spouse, child, stepchild, parent, sibling, or domestic partner) involved as an investor, owner,
employee, consultant, contractor, or board member with an entity that has a contractual relationship with YOUR
ORGANIZATION to provide goods or services, sponsor development activities and/or receive referrals from YOUR
ORGANIZATION?
Y
ES NO (if YES, please complete Part C of the Attachment)
D. Gifts for Personal Use:
To the best of your knowledge, have you or your family members accepted gratuity gifts, or special favors from someone that is
doing business with or proposing to do business with YOUR ORGANIZATION?
YES NO (if YES, please complete Part D on Attachment)
To t
he best of your knowledge, have you or your family members made any donations or gifts, or provided special favors to
YOUR ORGANIZATION or any employee of the YOUR ORGANIZATION who exercises or may exercise any functions or
responsibility with respect to the activities involving your award, contract or program assistance.
Y
ES NO (if YES, please complete Part D on Attachment)
