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<br />.,. - <br /> <br />DAKOTA MEDICAL FOUNDATION/DAKOTA MEDICAL CHARITIES <br />ORGANIZATIONAL ENTITY GRANTEE <br />CONFLICTS OF INTEREST DISCLOSURE FORM <br /> <br />5/02 <br /> <br />Grantee acknowledges that Grantee must continuously disclose Grantee's potential <br />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 Grantee, including benefits to Grantee and Grantee's related <br />persons, which include without limitation, Grantee's directors, trustees, officers, committee <br />members or key employees, or immediate family members thereof. <br /> <br />Thus, the President/Executive Director (or equivalent thereof) of Grantee, and the <br />President/Chair (or equivalent thereof) of the Board of Directors of Grantee, shall complete, <br />or arrange for the completion of this Foundation Conflicts of Interest Disclosure Form <br />("form") and shall have a continuing obligation to immediately update the form if at any time <br />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 Grantee and Grantee's related persons may have with the Foundation and any <br />of the Foundation's officers, directors and staff, including without limitation, any <br />opportunities that Grantee and Grantee's related persons may have to direct the use of <br />the Foundation's funds to any of Grantee's related persons may have to direct the use of <br />the Foundation's funds to any of Grantee's related persons' immediate family members, <br />or any organization in which Grantee or Grantee's related persons have a financial <br />interest or position of control. <br /> <br />I have the following concerns about any potential conflicts of interest that Grantee or <br />Grantee'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 />7 _d-I__ d3 <br /> <br />Date <br /> <br />'~ ~~~","" <br /> <br />Signature of President/Chair (or equi <br />of the Board of Directors of Grantee <br /> <br />'7-- 2 )-() 3 <br />Date .. <br /> <br />6 <br />