Please initial in the space at the end of Item A or complete Item B, whichever is appropriate, complete Item C, and sign and date the statement and return it to the board chair.

I am not aware of any relationship or interest or situation involving my family or myself which might result in, or give the appearance of being, a conflict of interest between such family member or me on one hand and JCS on the other. _______

The following are relationships, interests or situations involving me or a member of my family which I consider might result in or appear to be an actual, apparent or potential conflict of interest between such family members or myself on one hand and JCS on the other. _______

For-profit corporate directorships, positions and employment with;

Nonprofit trusteeships of positions: _______________________________________________________________

Memberships in the following organizations: _______________________________________________________

Contracts, business activities and investments with or in the following organizations: _______________________

___________________________________________________________________________________________

Other relationships and activities.

C.	My primary business or occupation at this time is: __________________________________________________

I have read and understand JCS's conflict-of-interest policy and agree to be bound by it. I will promptly inform the board chair of JCS of any material change that develops in the information contained in the foregoing statement.

Type/Print Name: _________________________________________

Signature: _______________________________________________	Date: ___________________

Adapted with permission from a disclosure statement drafted by the National Center for Nonprofit Boards.

Original Form: 04/17/02

Revised Form: 12/08/06

Revised Form: 09/08/17