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Conflict of Interest and Disclosure Report

Use this form for all interests required to be disclosed that impact your employment and/or obligations as an official with Company Name and comply with Insert your State or Company Policy Reference here, or let this stand "as is". This report must be filed annually for all Directors and Officers. Additional sheets may be attached as necessary. A Supervisor must complete the following form and file it with the Human Resources Department.

IMPORTANT: When answering each question in this form, you must include sources of income and disclosures as they apply to your spouse and dependent children.

Sources of Income

Please list all your sources of income of more than $600 per year. Sources of income to list include salaries, hourly employment, directorships, dividend and investment income, interest payments, annuities or other settlements.

Investments and Ownership

Please list any investments in or ownership of public or private corporations, stock or other business organizations that are in excess of $5,000 or constitute a 5% or greater ownership stake. You are not required to list specific amounts of your investments. Instead you should specify, as an example, that you have an investment in "xyz" firm who is in the "abc" industry.

Lobbying and Retainer Fees

Please list any persons, firms, or organizations for whom lobbying, compensated or not, is performed by you or your family members. Please include non-dependent children in your answer for this question.

Professional Services

Please list all professional services you or your spouse provide, such as attorney, accountant, or consultant, and the interests that you provide them for as a general overview (e.g., industry, company type, etc. Please list any bankruptcy, default, or discharge of debt received in any United States District Court within the last ten years of the date on this form.

Loans and Debt

Please list all loans or combination of loans that total more than $1,000 from the same source. Private loans made to family or children are not required to be disclosed, provided that you are not a co-signer on an instrument of debt for a loan made to family or children.

Additional Information

Please list all other financial disclosures or disclosures of employment, offices or positions held, public service or legislative employment, or any other disclosure you want to make. Employee / Officer Signature Date.

Supervisor Signature Date

For Office Use Only

Received By signator, authorized signature or signer

Human Resources Manager Date

Human Resources Name

Human Resources Phone

Human Resources Email