HCCF CONFIDENTIALITY COMMITMENT AND CONFLICT OF INTEREST DISCLOSURE

Please refer to our Conflict of Interest Policy and Confidentiality Policy before completing and submitting this form.

Name*
First Last
Role with HCCF*
- Employee
- Director
- Volunteer
I currently serve as a director, trustee, officer, or in an official or executive capacity with a charitable or nonprofit organization(s) that may seek a grant from HCCF and/or could potentially create a self-dealing or conflict of interest situation.
- I do so serve
If yes, disclose the organization(s) and your relationship to the organization(s).
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
I have a relationship with someone (spouse, domestic partner, child, parent, sibling, or close associate) who currently serves as a director, trustee, officer, or in an official or executive capacity with a charitable or nonprofit organization that may seek a grant from HCCF and/or could potentially create a self-dealing or conflict of interest situation.
- I do
If yes, disclose your relationship to the individual, the organization(s) they are affiliated with and your relationship to the organization(s).
Individual/Relationship Organization Name Individual's Relationship to Organization
Individual/Relationship Organization Name Individual's Relationship to Organization
Individual/Relationship Organization Name Individual's Relationship to Organization
I am currently employed by or affiliated with a vendor, supplier, corporation, or any other party providing or bidding for providing services, having a direct or indirect interest in any business transaction(s), agreement, investment with HCCF.
- I am
If yes, disclose the organization(s) and your relationship to the organization(s).
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
Organization
Name Relationship to Organization
I have a relationship with someone (spouse, domestic partner, child, parent, sibling, or close associate) who is currently employed by or affiliated with a vendor, supplier, corporation, or any other party providing or bidding for providing services, having a direct or indirect interest in any business transaction(s), agreement, investment with HCCF.
- I do
If yes, disclose your relationship to the individual, the organization(s) they are affiliated with and your relationship to the organization(s).
Individual/Relationship Organization Name Individual's Relationship to Organization
Individual/Relationship Organization Name Individual's Relationship to Organization
Individual/Relationship Organization Name Individual's Relationship to Organization
I have read HCCF's Conflict of Interest policy approved by the Board of Directors and understand that as an Employee/Director/Officer of HCCF, it is my obligation to act in a manner that promotes the best interests of HCCF and to avoid conflicts of interest when making decisions and taking actions on behalf of HCCF.

My answers to this disclosure form are correctly stated to the best of my knowledge and belief. Should a possible conflict of interest arise in my responsibilities to HCCF, I recognize that I have the obligation to notify, based on my position, the appropriate designated individual (Chairman, President), and to abstain from any participation in the matter until HCCF can determine whether a conflict exits and how that conflict shall be resolved. If any relevant changes occur in my affiliations, duties, or financial circumstances, I recognize that I have a continuing obligation to file an amended "Conflict of Interest Disclosure Form" with the appropriate designated office.

I have read and understand the Confidentiality Policy and shall exercise care not to disclose confidential information in connection with my affiliation with HCCF.
I understand that the information on this form is solely for use by HCCF and is considered confidential information. Release of this information within HCCF will be on a need-to-know basis only. Release to external parties will be only when required by law.
SIGNATURE*
First Last
Date*
MM slash DD slash YYYY

HCCF CONFIDENTIALITY COMMITMENT AND CONFLICT OF INTEREST DISCLOSURE

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