WWALS Conflict of Interest Statement

WWALS Watershed Coalition, Inc. (WWALS)
CONFLICT OF INTEREST 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:

  1. your spouse, domestic partner, child, mother, father, brother or sister;
  2. any 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
  3. any trust or other estate in which you have a substantial beneficial interest or as to which you serve as a trustee or in a similar capacity.

  1. NAME OF EMPLOYEE OR BOARD MEMBER: (Please print)
     

  2. CAPACITY:
    ______board of directors
    ______executive committee
    ______officer
    ______committee member
    ______staff (position): ____________

  3. Have you or any of your affiliated persons provided services or property to WWALS in the past year?
    _____YES _____NO

    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:



  4. Have you or any of your affiliated persons purchased services or property from WWALS in the past year?
    _____YES _____NO

    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:



  5. 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 WWALS was or is a party?
    _____YES _____NO

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



  6. Were you or any of your affiliated persons indebted to pay money to WWALS any time in the past year (other than travel advances or the like)?
    _____YES _____NO

    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:



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

    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:



  8. Are you or any of your affiliated persons a party to or have an interest in any pending legal proceedings involving WWALS?
    _____YES _____NO

    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:



  9. Are you aware of any other events, transactions, arrangements or other situations that have occurred or may occur in the future that you believe should be examined by WWALS’ [board or a duly constituted committee thereof] in accordance with the terms and intent of WWALS’ conflict of interest policy?
    _____YES _____NO

    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 HERBY CONFIRM that I have read and understand WWALS’ conflict of interest policy s 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.

___________________________________
Signature

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Date

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