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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
3556 Winslow Road, Marion, IA 52302
Adopted: 1/22
Revised: 10/22; 9/24
Related Policy: 202.7
IASB Reference: 203