Conflict of Interest Questionnaire Disclosure

  • Conflict of Interest Questionnaire

    If no conflict of interest exists:

    Box 1: Name of vendor's business/company

    Box 3: N/A 

    Box 7: Signature and Date

     

    If there is a conflict of interest:

    Box 1: Name of vendor’s business/company

    Box 2: Check only if this questionnaire is a “follow-up” to a previously filed form

    Box 3: Name of Officer

    Box 4: If there IS a conflict of interest in regards to the vendor and the superintendent or board member(s) &/or a member of their family in the “first degree,” Box 3 should be completed with the name(s) of the person(s) who have a business relationship with the vendor and the type of relationship that causes the potential conflict of interest.

    Example: Jane Does, wife of John Doe, who is a LEISD board member, has an interest bearing account in her name at ABC.

    Submit, again, the name(s) represented in Box 3. On item “A,” check whether or not the affected person from Box 3 is receiving or is likely to receive any taxable income from the vendor. Item “B” is to determine if the vendor is receiving or is likely to receive any taxable income from any actions on the part of a board member or superintendent. Item “C” is to determine if the vendor is affiliated with a business in which the superintendent or school board member serves on the board of directors of the vendor’s business/corporation, or is part or full owner of the business. Item “D” is to simply describe any/all other relationships that would help to disclose a potential conflict of interest between a vendor and the superintendent, each school board member, and/or their families in the first degree.

    Box 5: Describe each employment or business relationship that the vendor named in Section 1

    Box 6: Check this box if the vendor has given the local government officer or family member of the officer one or more gifts

    Box 7: Signature and Date