Conflict of Interest Declaration

R-23

• NOTE: This Declaration must be completed and signed annually by all paid staff, volunteers, board and committee members who are involved in financial decisions or transactions (see 200.2.9).

   

  I have read the policy entitled “Conflict of Interest.” I accept it as my responsibility to disclose in writing a full description of any activity, interest or relationship on my part that might create or appear to create a conflict of interest under the provisions of the policy, as soon as practicable after the inception of the activity, interest or relationship.

  To the best of my knowledge and belief, I am not now engaged in any activity, interest or relationship that would create or appear to create a conflict of interest under the terms of the Conflict of Interest Policy, except as indicated below. I agree to maintain my affairs in compliance with the policy.

  All paid staff, volunteers, board and committee members involved in financial decisions or transactions must submit this form annually to your state office by January 15.

• The only situation(s) that could possibly give rise to the appearance of a conflict of interest is (are) as follows: