Complete Form

Federal Funding Subrecipient Conflict of Interest Annual Affirmation of Compliance - Employees

I have received and carefully read the BBBSA Conflict of Interest Policy and have considered the literal expression of the policy and its intent. By signing this affirmation, I confirm that I understand and will comply with the Policy. I further understand that BBBSA is a nonprofit organization and that, in order to maintain its federal tax exemption, it must engage primarily in activities that accomplish one or more of its tax-exempt purposes without personal gain (other than by salary) by board members or staff.

Except as otherwise indicated below, I hereby state that I do not have any conflict of interest, financial or otherwise, that may be seen as competing with the interests of BBBSA, nor does any relative or associate have such a potential conflict of interest, nor shall I, any relative, or associate benefit from any action, policy, or transaction made by BBBSA in a manner that has not been previously disclosed.

If any situation should arise in the future that I think may involve me in a conflict of interest, I will make a prompt and full written disclosure of the circumstances.

I wish to disclose the following organizations for which I serve on the Board of Directors (please include
any and all for-profit and non-profit organizations), as well as any other potential conflicts of interest:

Name: