Annual conflict of interest disclosure questionnaire
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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 organization | Your (or family member's) role and ownership share | Its 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:

| Who | What the transaction was | Approximate amount | Date | Was 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]