202.7-E - Board of Directors Conflict of Interest Disclosure Form

Click here to download a copy of the Board of Directors Conflict of Interest Form

I hereby certify that I have, or may have, a financial interest or conflicting interest as noted below. The potential conflict is with the following individual and/or organization with which the Linn-Mar CSD has, or might reasonably have in the future, a relationship with; or which Linn-Mar CSD may enter into a transaction with or compete with.

Name of conflicting or financial interest (individual or company, etc.):

_____________________________________________________________________________________

Reason for potential conflict (e.g. family relationship, financial relationship, etc.):

_____________________________________________________________________________________

All facts pertinent to the conflicting or financial interest:

_____________________________________________________________________________________

_____ I have no conflict of interest to disclose.

_____ I hereby certify that I have read and understand Policy 202.7 Board of Directors Conflict of Interest, which I received a copy of, and that the above information is true, correct, and complete to the best of my knowledge, information, and belief. I further certify that I will comply with the requirements of Policy 202.7 Board of Directors Conflict of Interest.

Board Member’s Signature: ________________________________________ Date: ________________

Printed Name: ____________________________________________ Fiscal Year: ___________________

Complete additional forms for multiple conflicts/financial interests, as needed.

Please return this form to:
LMCSD School Board Secretary/Treasurer
2999 N 10^th Street, Marion, IA 52302 

Adopted: 1/22
Revised: 10/22
Related Policy: 202.7