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Conflict of Interest & Disclosure

Conflict of Interest and Disclosure Statement

Preliminary note: In order to be more comprehensive, this statement of disclosure/questionnaire also requires you to provide information with respect to certain parties that are related to you. These persons are termed “affiliated persons” and include the following:

Your spouse, domestic partner, child, mother, father, brother or sister;
and corporation or organization of which you are a board member, an officer, a partner, participate in management or are employed by, or are, directly or indirectly, a debt holder or the beneficial owner of any class of equity securities;
and any other trust or other estate in which you have a substantial beneficial interest or as to which you serve as a trustee in a similar capacity.

Capacity (check all that apply)

Board of Directors

Officer

Development Committee

Finance Committee

Governance Committee

1. Have you or any of your affiliated persons provided services of property to Cradle of Hope in the past year?

If yes, please describe the nature of the services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

2. Have you or any of your affiliated persons purchased services or property from Cradle of Hope in the past year?

If yes, please describe the purchased services or property and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

3. Please indicate whether you or any of your affiliated persons had any direct or indirect interest in any business transaction(s) in the past year to which Cradle of Hope was or is a party?

If yes, please describe the transaction(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

4. Were you or any of your affiliated persons indebted to pay money to Cradle of Hope at any time in the past year (other than travel advances or the like)?

If yes, please describe the indebtedness and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

5. In the past year, did you or any of your affiliated persons receive, or become entitled to receive, directly or indirectly, and personal benefits from Cradle of Hope or as a result of your relationship with Cradle of Hope, that in the aggregate could be valued in the excess of $1,000 that were not or will not be in compensation directly related to your duties to Cradle of Hope?

If yes, please describe the benefit(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

6. Are you or any of your affiliated persons a party to or have an interest in any pending legal proceedings involving Cradle of Hope?

If yes, please describe the proceeding(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

7. Are you aware of any other events, transactions, arrangements or other situations that have occurred in the future that you believe should be examined by Cradle of Hope's (board or a duly constituted committee thereof) in accordance with the terms and intent of Cradle of Hope's conflict of interest policy?

If yes, please describe the situation(s) and if an affiliated person is involved, the identity of the affiliated person and your relationship with that person:

I HEREBY CONFIRM that I have read and understand Cradle of Hope’s conflict of interest policy and that my responses to the above questions are complete and correct to the best of my information and belief. I agree that if I become aware of any information that might indicate that this disclosure is inaccurate or that I have not complied with this policy, I will notify (designated officer or director) immediately.

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January 22, 2022 4:04 pm CDT

Conflict of Interest & Disclosure Uploaded by Darlene Kopesky - dkopesky@cradleofhope.org IP 73.62.185.83