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<br />-. <br /> <br />DAKOTA MEDICAL FOUNDATION/DAKOTA MEDICAL CHARITIES <br />ORGANIZATIONAL ENTITY GRANT PARTNER <br />CONFLICTS OF INTEREST DISCLOSURE FORM <br /> <br />8/02 <br /> <br />Grant partner acknowledges that Grant partner must continuously disclose Grant partner's <br />potential conflicts of interest with Dakota Medical Foundation/Dakota Medical Charities <br />("Foundation") so that the Foundation can protect its tax-exempt status by avoiding <br />transactions, arrangements, or uses of the Foundation's funds that might unreasonably <br />benefit the private interests of Grant partner, including benefits to Grant partner and Grant <br />partner's related persons, which include without limitation, Grant partner's directors, <br />trustees, officers, committee members or key employees, or immediate family members <br />thereof. <br /> <br />Thus, the President/Executive Director (or equivalent thereof) of Grant partner, and the <br />President/Chair (or equivalent thereof) of the Board of Directors of Grant partner, shall <br />complete, or arrange for the completion of this Foundation Conflicts of Interest Disclosure <br />Form ("form") and shall have a continuing obligation to immediately update the form if at <br />any time throughout the grant period there is new information to report on the form. <br /> <br />Potential Conflicts <br /> <br />I acknowledge that the Foundation must be informed about any potential conflicts of <br />interest Grant partner and Grant partner's related persons may have with the Foundation <br />and any of the Foundation's officers, directors and staff, including without limitation, <br />any opportunities that Grant partner and Grant partner's related persons may have to <br />direct the use of the Foundation's funds to any of Grant partner's related persons may <br />have to direct the use of the Foundation's funds to any of Grant partner's related <br />persons' immediate family members, or any organization in which Grant partner or <br />Grant partner's related persons have a financial interest or position of control. <br /> <br />I have the following concerns about any potential conflicts of interest that Grant partner <br />or Grant partner's related persons may have with the Foundation and any of its officers, <br />directors and staff: <br /> <br />I have, to the best of my knowledge, disclosed all potential or actual conflicts of interest <br />with the Foundation. I agree to immediately report to the Foundation, any changes in my <br />above representations. <br /> <br /> <br />J / J.;- tJ3 <br />Dale <br /> <br />;- Z-l-o 3 <br />Date <br /> <br />6 <br />