Subject: Ethical Practice

COA: ETH 2.01, ETH 2.02, ETH 2.03 Applies to: All organization

Conflict of Interest Disclosure Form

Form Number: 1011-02 Effective: June 27, 2007 Revision effective: January 30, 2013 Reviewed: January 30, 2013

Name

Date

I agree to disclose all known conflicts in which my actions, as a board director, employee, or volunteer may influence financial-related decisions. I will answer yes to statements a - d below if the answer is affirmative as to myself, any of my family members,** or any business in which I or my family member(s) serve as an officer, director, or own 35% or more interest. If I answer in the affirmative to any of the statements below, I will refrain from discussion or voting in connection with such matters. a. Received any direct or indirect payment, loan, grant, or other cash or non-cash economic benefit from the Agency (excluding salary/wage and associated payroll benefits received by agency employees) Yes No

b. Made any direct or indirect payment, loan or grant outside the mission of Catholic Charities as promoted by the Advancement Office Yes c. No

Leased any office, other real property, equipment, or other personal property from the Agency Yes No

d. Entered into any contract, agreement or arrangement for the provision of goods or services (including but not limited to legal, accounting, banking, insurance, or consulting services) to the Agency Yes No

If you answered Yes to any of the above, please explain: ___________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

FOR EMPLOYEES ONLY: Are you engaged in any secondary employment? Yes No If Yes, refer to the ETH- Conduct and Ethical Practice policy and the Outside Employment section of the Employee Handbook for additional information.

Signature This document is to be signed annually.

Date

**Family members include a spouse, child or spouse of a child, brother, sister, or spouse of a brother, or sister of a Board Director, volunteer, or employee