Annual Affirmation of Compliance and Disclosure Statement
I have received and carefully read the Conflict of Interest Policy for board members, staff, and volunteers of Pennsylvania Parks and Forests Foundation, Inc. and have considered not only the literal expression of the policy, but also its intent. By signing this affirmation of compliance, I hereby affirm that I understand and agree to comply with the Conflict of Interest Policy. I further understand that Pennsylvania Parks and Forests Foundation Inc. 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.

Except as otherwise indicated in the Disclosure Statement and attachments, if any, below, I hereby state that I do not, to the best of my knowledge, have any conflict of interest that may be seen as competing with the interests of Pennsylvania Parks and Forests Foundation Inc., nor does any relative or business associate have such an actual or potential conflict of interest.

If any situation should arise in the future which I think may involve me in a conflict of interest, I will promptly and fully disclose the circumstances to the Chairman of the Board of Directors of Pennsylvania Parks and Forests Foundation, Inc. or to the President, as applicable.

I further certify that the information set forth in the Disclosure Statement and attachments, if any, is true and correct to the best of my knowledge, information and belief and that by typing my name in the space provided I am affirming the truth of the answers given just as though I had signed a printed document.

(c) 1998-2009 Maryland Association of Nonprofit Organizations d/b/a Standards for Excellence Institute, offered under licensing agreement through the Pennsylvania Association of Nonprofit Organizations. Permission granted for use by nonprofit organization members of the association.
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Certified and Affirmed by: *
Calendar Year for Which Disclosure is Provided: *
Position with PPFF/Chapter: *
Chapter Represented: *
Date Signed: *
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DISCLOSURE STATEMENT
Please complete the questionnaire below indicating any actual or potential conflicts of interest. If you answer “yes” to any of the questions, please provide a written description of the details of the specific action or transaction in the space allowed. Attach additional sheets as needed.

Financial Interests - A conflict may exist where an interested party, or a relative or business associate of an interested party, directly or indirectly benefits or profits as a result of a decision made or transaction entered into by the organization.

Please indicate, during the past 12 months:

Has the organization contracted to purchase or lease goods, services, or property from or otherwise had a direct business relationship with you or any of your relatives or business associates? 

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If yes, please describe:

Has the organization purchased an ownership interest in or invested in a business entity owned by you or owned by any of your relatives or business associates? 

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If yes, please describe:

Has the organization offered employment to you, or to any of your relatives or business associates, other than a person who was already employed by the organization? 

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If yes, please describe:

Have you, or have any of your relatives or business associates, been provided with a gift, gratuity or favor, of a substantial nature, from a person or entity which does business, or seeks to do business, with the organization?

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If yes, please describe:

Have you, or any of your relatives or business associates, been gratuitously provided use of the facilities, property, or services of the organization or received a grant, loan or other financial assistance from the organization? 

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If yes, please describe:

Has a relative had a direct or indirect business relationship with the organization?

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If yes, please describe:

Have you served as an officer, director, trustee, key employee, partner, or member/shareholder of an entity doing business with the organization?

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If yes, please describe:
Other Interests:
A conflict may also exist where an interested party, or a relative or business associate of an interested party, obtains a non-financial benefit or advantage that he/she would not have obtained absent his/her relationship with the organization, or where his/her duty or responsibility owed to the organization conflicts with a duty or responsibility owed to some other organization.

Please respond to the following questions indicating if you had this activity anytime during the past twelve months:

Did you obtain preferential treatment by the organization for yourself, or for any of your relatives or business associates?

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If yes, please describe:

Did you make use of confidential information obtained from the organization for your own benefit, or for the benefit of a relative, business associate, or other organization? 

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If yes, please describe:

Did you take advantage of an opportunity, or enable a relative, business associate or other organization to take advantage of an opportunity, which you had reason to believe would be of interest to the organization?

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If yes, please describe:
Please outline any other situation or scenario or provide any other information which would be helpful to share.
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