Template · Governance

Annual conflict of interest disclosure questionnaire

A fill-in questionnaire for board members, officers and key staff that collects the interests, relationships and transactions Form 990 asks about each year.

Three editable formats: Word (.docx), Rich Text (.rtf) and plain text (.txt). Reviewed October 22, 2026.

How to use this template

  1. Download it as a Word file (.docx), which opens in Microsoft Word, Google Docs, Pages and LibreOffice, or as Rich Text (.rtf) or plain text (.txt). All three are editable.
  2. Fill in every blank. Blanks are in square brackets, like [ORGANIZATION NAME], and are highlighted in the preview below. Delete any bracketed notes you don't need.
  3. Make it yours. Check it against your bylaws and your state's rules, and change anything that doesn't fit. Have your board approve it where it says so.
  4. Printing? Print this page: the printout leaves out the site's menus and shows the template with lines for the blanks.

Your conflict of interest policy sets the rules and ends with a short annual statement that people sign to say they've read and will follow it. This questionnaire goes further. It asks the specific questions that help your board spot conflicts before they happen, and gathers the information your Form 990 asks for, in one form people fill in once a year.

Why a questionnaire

The IRS instructions for Form 990, Part VI, explain several questions this form helps you answer:

  • Line 12b asks whether officers, directors, trustees and key employees are required to disclose or update, annually or more often, "information regarding their interests and those of their family members that could give rise to conflicts of interest, such as a list of family members, substantial business or investment holdings, and other transactions or affiliations with businesses and other organizations and those of family members."
  • Line 12c asks you to describe how you monitor transactions for conflicts and deal with them.
  • Line 2 asks whether any officers, directors, trustees or key employees had a family or business relationship with each other during the year. The instructions say a reasonable effort to get this information is enough, and give as an example distributing a questionnaire each year with each person's name and title, a place to sign and date, and the instructions and definitions for line 2.
  • Line 1b asks how many voting board members are independent. The instructions say the organization can rely on a questionnaire sent each year to each board member for this too.

Some states require annual disclosure by law. In New York, for example, Not-for-Profit Corporation Law § 715-a requires the conflict of interest policy to say that, before a director is first elected and every year after, the director completes, signs and submits a written statement identifying any entity they're an officer, director, trustee, member, owner or employee of that has a relationship with the corporation, and any transaction with the corporation in which they might have a conflicting interest. The statements go to the secretary or a designated compliance officer, who gives copies to the chair of the audit committee, or of the board if there's no audit committee. Check your own state's nonprofit law.

Key definitions from the Form 990 instructions

  • Family includes a person's spouse, ancestors, brothers and sisters (whole or half blood), children (natural or adopted), grandchildren, great-grandchildren, and the spouses of brothers, sisters, children, grandchildren and great-grandchildren.
  • Business relationships between two people include: one employing the other (or working for an organization where the other is a trustee, director, officer or greater-than-35% owner); doing business with each other worth more than $10,000 in total during the year, other than in the ordinary course of business on terms generally offered to the public; or both being a director, trustee, officer or greater-than-10% owner of the same business or investment entity. Attorney and client, medical professional and patient, and clergy and penitent relationships don't count.
  • Independent board members, in short, weren't paid as an officer or employee, didn't receive more than $10,000 as an independent contractor (other than reasonable pay for serving on the board), and weren't involved, with their family, in a transaction reportable on Schedule L. Being a donor doesn't make someone not independent. See the instructions for the full test.

How to use it

  • Send it at the same time every year, for example a month before your annual meeting, and to every new board member or officer before they start.
  • Have the secretary collect the forms and give the chair (or the audit committee chair) a short summary of anything disclosed.
  • Act on what you learn. A disclosure isn't a problem; a hidden conflict is. Follow your policy: the person discloses, steps out of the discussion and vote, and the minutes record it.
  • Keep the signed forms with your board records, under your document retention policy.
  • Use the answers for your Form 990, Part VI and Schedule L. Ask your accountant how they apply.

Preview

Annual conflict of interest disclosure questionnaire

[ORGANIZATION NAME]

Year covered: [YEAR] (our fiscal year runs [START DATE] to [END DATE])

Please return to [SECRETARY OR COMPLIANCE OFFICER] by [DATE]. If you're unsure whether something counts, disclose it; the board will decide. Answer for yourself and your family as defined in the instructions above.

Part 1. About you

  • Name: [NAME]
  • Role(s) at [ORGANIZATION NAME]: [DIRECTOR / OFFICER (TITLE) / KEY EMPLOYEE / COMMITTEE MEMBER]
  • Voting member of the board: [YES / NO]

Part 2. Pay and payments from the organization

  1. During the year, were you paid by [ORGANIZATION NAME] or a related organization as an officer or employee? [YES / NO]
  2. Did you receive more than $10,000 in total from [ORGANIZATION NAME] or a related organization as an independent contractor (not counting reasonable pay for board service and reasonable expense reimbursements)? [YES / NO]
  3. Did any family member receive pay or other payments from [ORGANIZATION NAME] or a related organization? [YES / NO] If yes, who, for what, and how much: [DETAILS]

Part 3. Your business and organizational interests

List any business or organization of which you or a family member is an owner, partner, director, trustee, officer or employee, and which does business with, competes with, receives grants from, or seeks money from [ORGANIZATION NAME]. Write "None" if none.

Name of business or organizationYour (or family member's) role and ownership shareIts relationship with [ORGANIZATION NAME]
[NAME][ROLE, % OWNED][FOR EXAMPLE: SUPPLIER, LANDLORD, GRANTEE, PARTNER]

Part 4. Transactions with the organization

During the year, did you, a family member, or a business or organization listed in Part 3 take part in any transaction with [ORGANIZATION NAME], such as a sale, lease, loan, contract for services, or grant? [YES / NO]

If yes, describe each one:

WhoWhat the transaction wasApproximate amountDateWas it approved by the board, and did you step out of the vote?
[NAME][DESCRIPTION][$][DATE][DETAILS]

Part 5. Relationships with other leaders

During the year, did you have a family relationship or a business relationship (as defined in the instructions above) with any other director, officer, trustee or key employee of [ORGANIZATION NAME]? [YES / NO]

If yes, name the person and say whether it is a family or business relationship: [DETAILS]

Part 6. Gifts and other benefits

During the year, did you or a family member receive any gift, payment, loan, discount or other benefit worth more than [$ AMOUNT] from anyone who does business with, or wants to do business with, [ORGANIZATION NAME]? [YES / NO] If yes: [DETAILS]

Part 7. Anything else

Is there anything else, including a possible future conflict, that the board should know about? [DETAILS OR "NONE"]

Part 8. Confirmation

By signing, I confirm that:

  1. I have received, read and understood the conflict of interest policy of [ORGANIZATION NAME], and agree to follow it.
  2. The answers above are complete and true to the best of my knowledge.
  3. I will tell [SECRETARY OR CHAIR] promptly, in writing, if anything changes before the next questionnaire.
  4. I understand that [ORGANIZATION NAME] is a charitable organization and, to keep its federal tax exemption, must engage mainly in activities that accomplish one or more of its tax-exempt purposes.

Signature: [SIGNATURE]

Date: [DATE]

For office use

  • Received by: [NAME] on [DATE]
  • Disclosures summarized for: [CHAIR / AUDIT COMMITTEE CHAIR] on [DATE]
  • Action taken, if any: [DETAILS]
  • Used for Form 990 for the year: [YEAR]

General information. Not legal, tax or financial advice. Rules change and every situation is different, so check the official sources and talk to a qualified professional before you act. More about this.

Keep going

Sources

Checked on October 22, 2026. Rules and fees change, so follow the links for the current version.

  1. IRS: Instructions for Form 990, Part VI, Lines 1b, 2 and 12
  2. New York Not-for-Profit Corporation Law § 715-a, Conflict of interest policy (an example of state law)

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