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. 


1. 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. _______



2. 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
# ____ JCS, Inc. ___ Form                                                                Page  of 2