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Director And Officer Conflict Of Interest Disclosure Form

(Annually for 990 disclosure)

Name:
Position:

A. To the best of your knowledge is the Cincinnati Youth Collaborative engaged in any transaction, financial arrangement, grants or assistance to interested parties or business relationship with any of the following?

Note: "Transaction", "financial arrangement", “grants or assistance to interested parties” and "business relationships" include the sale, exchange, transfer or lease of property to or from a related party; loans to or from a related party; an investment in a related party; the furnishing of goods, services or facilities to a related party or by a related party for compensation; awards, prizes, scholarships, fellowships, internships and other types of assistance to a related party; payment of wages, salary, or compensation to a related party; or the transfer of income or assets to a related party

1. You:	Yes No
2. Any of your relatives, as follows:
a. Spouse	Yes No
b. Children	Yes No
c. Grandchildren	Yes No
d. Siblings	Yes No
e. Parents	Yes No
f. Grandparents	Yes No
If “yes” please describe the nature of the business transaction, the person involved, the total amount paid by corporation during the year and whether the payment by the corporation was based on a percentage of the corporation’s revenues
3. Any entity or institution (for profit or nonprofit) that is owned or controlled by:
a. You	Yes No
b. Any relatives listed above:	Yes No
c. Any combination of:
I. You	Yes No
II. Your relatives listed above	Yes No
III. Individuals (besides yourself) serving as directors officers or managers of the organization Yes No
If “yes” please describe (see above):

B. Do you anticipate engaging in any transaction or financial arrangement that might create a conflict of interest for you?

Yes

If "yes" please describe:

C. Will you disclose, in writing, to the Chairperson of the Board (or Treasurer, if Chairperson is respondent) any future transaction or financial arrangement that might create a conflict of interest for you?

Yes

D. Will you refrain from participating in any business matter of the Cincinnati Youth Collaborative or a subsidiary in which you have a conflict or potential conflict of private or business interest, unless you have the prior approval as outlined in the Conflict-of-Interest Policy?

Yes

E. Do you understand that no conflict of interest shall be deemed to exist and no disclosure shall be required solely because the interested person, or his or her spouse?

a) owns, for investment purposes, less than one percent of the stock of any publicly traded company with which the Organization conducts business; or

b) engages in ordinary course of dealing banking relationships for personal or business purposes.

Yes

F. List the organizations (other than the Organization or it Affiliates) of which you or your spouse are a director, trustee or officer.

I have read and understand the Organization’s “Directors and Officers Conflict of Interest Policy”. I agree to comply with the Policy. I understand that the Organization is a charitable organization and that in order to maintain its federal tax exemption it must engage primarily in activities which accomplish one or more of its tax-exempt purposes.

My answers to this questionnaire are correctly stated to the best of my knowledge and belief. Should a possible conflict of interest arise in my responsibilities to the Organization, I recognize that I have the obligation to notify the Chairperson of the Board of Directors or the President and to abstain from any participation in the matter until the Board of Directors can determine whether a conflict exists and how any conflict shall be resolved.

“Related Party” means any of the individuals or entities listed in Questions A- 1, A-2 and A-3 of this Disclosure Form.

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August 21, 2024 4:05 pm EST

Director And Officer Conflict Of Interest Disclosure Form Uploaded by Chris Lipscombe - [email protected] IP 208.102.103.31

August 30, 2024 1:58 pm EST

Patti Shepard - [email protected] added by Chris Lipscombe - [email protected] as a CC'd Recipient Ip: 208.102.103.31