Conflict of Interest A and D Form

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Conflict of Interest A and D Form

SFDS Conflict of Interest Acknowledgement and Disclosure Form

Do you receive compensation as an officer, director, committee member, or task-force member of SFDS?

Yes
No

Other than reimbursement of reasonable expenses, have you received, or do you expect to receive, more than $10,000 per year from SFDS for services provided as an independent contractor?

Yes
No

Have you received, or do you expect to receive any material financial benefit from SFDS in addition, or apart from the benefits described in the above inquiries?

Yes
No

Does any family member receive compensation or material financial benefit from SFDS?

Yes
No

Do you have a family relationship or business relationship with any current officer, director, or key employee of SFDS? *1

Yes
No

If you answered “Yes” to any of the above or have any potential conflicts of interest, please explain below.

I understand the Organization is tax-exempt and to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes.

Yes
No

I understand that board and committee members’ powers are invested for the good of all members of the organization rather than for personal benefit.

Yes
No

I agree to preserve the confidentiality of any information that comes into my possession or that is designated or treated as confidential by the association.

Yes
No

I agree to be particularly careful to not disclose legal information that come to the association through inside or outside legal counsel.

Yes
No

I have received a copy of the Conflict of Interest policy. Further, I have read, understand and agree to comply with said policy.

Yes

Electronic Signature

Please type your name as an electronic signature

Date signed

*1 This question does not apply to attorney-client or doctor-patient relationships, nor does it apply to relationships with clergy members.

Please check the box above

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